Episode 9: The Shouldice Hernia Repair | Hernia Talk Q&A

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Speaker 1 (00:00:00):

Here we go. So welcome everyone. This is Hernia Talk Live. We have a weekly session now that is live with questions and answers from you the patients to us me, I’m Dr. Sharon Towfigh. As you know I live and Breathe Hernias and I work in Beverly Hills at the Beverly Hills Hernia Center. And you can follow me on all the different social media platforms at Hernia doc. And after we are done with this session, I will make sure that you have access to re-review this live session. Today we have the lovely Dr. Fernando Spencer Netto. He is the hernia specialist and full-time surgeon at the Shouldice Hospital outside Toronto, Canada. He is not as fun with social media, but he does have Facebook and <laugh> Instagram, which you can follow. And I would like to very much welcome Dr. Spencer Netto. Hello.

Speaker 2 (00:01:05):

Hello Shirin. Thanks for inviting me for this talk. Yes, I’m a little bit of caveman. I’m just doing a little as possible in the social media. Well, I like human interaction but COVID times is making it difficult.

Speaker 1 (00:01:20):

Yes. Well thank you for that first, thank you very much for coming. And you are a surgeon, hernia surgeon at the Shouldice Hospital. As you know the Shouldice Hospital is very, very famous for what it does. It is a standalone building, a hundred percent dedicated to hernia repairs. Inspired by Dr. The original Dr. Shouldice. And I think I told you I’ll share with the audience. I’ve had the privilege of being a guest there. I was invited with your previous kind of head, head surgeon there and Dr. Alexander Mylar and he was a lovely, lovely host. I got to watch the whole experience how patients check in the process of surgery, which I thought was fabulous. And it was just how do I say very unique because it was very different than the hospitals that I’ve worked in. And at the same time nowadays the hospital has really done a good job of getting the message out about tissue-based repair and what you guys offer. So I would like you to maybe give us a little bit of how you got involved working there and what is the patient experience and how are you different from mm-hmm. Let’s say going to a different, let’s say McGill or Toronto University. University of Toronto where I have friends to get their hernia repair.

Speaker 2 (00:03:05):

So initially my formation is a general surgeon, I’m Brazilian and first came here to Canada to do master of PhD back to Brazil and then back to Canada. My initial background was in trauma surgery and when you are not acute care surgery, you generally do general surgery, hernias and gallbladders. That is the simpler operations in general, simpler operations in general surgery. And over time you get more experience. You want to do less acute care and more control the environment surgeries well you can do a better job and you can have your time and more better spent. So that was the way that I got more involved in elective hernia surgery. And I still do a little bit of trauma calls but decreased significantly in number. It is not at Shouldice hospital because Shouldice is just an elective.

Speaker 1 (00:04:09):

Where do you work outside of Shouldice?

Speaker 2 (00:04:13):

Sunnybrook. But this is just for trauma. I just do. Got it. And Shouldice is,

Speaker 1 (00:04:22):

Yeah. Did you have to get special training to work there because I remember

Speaker 2 (00:04:26):


Speaker 1 (00:04:27):

All the surgeons one of the very, what’s very unique with the Shouldice, which I thought was great was everyone is trained to do the repair, the Shouldice repair, the same thing. And Dr. Alexander would rotate and scrub in with the surgions periodically to make sure the police, to make sure that whatever technique you are using has not wavered or changed from the original shouldice technique. Is that still true?

Speaker 2 (00:04:56):

That’s true. So I thought when I went to shouldice, that unusual technique, I used to kind of <inaudible> technique that was not exactly the way that they do that there. So even before I used to do lots of hernias, incisional hernias in hernias recurrent hernias a lot. But there need to retrain to do the technique and also a specific material. So instead of usual stitches for the hernia repair that most of people use Prolene for example, we use stainless steel wire. So it’s a little different now. I prefer the wire a lot, it’s a lot better to work with but in the beginning it take a little time to get used the tool

Speaker 1 (00:05:46):

And the wire is made onsite. I saw that there were workers that were making the wire sutures

Speaker 2 (00:05:54):

On site they prepared in the specific length that the surgeon wants and yeah.

Speaker 1 (00:06:01):

Yeah. Very cool. So when I saw, can you explain the patient journey? First of all, do you accept patients from all over the world?

Speaker 2 (00:06:10):

Yeah. Yeah. So basically we received the patient from all over the world. They initially contact through the website and there are some forms medical form that they need to fill out. Usually we do need a physician wherever the patient is in Brazil or Japan, US to certify that he has a hernia. It’s just not a ultra sonographic or CT or MRI a hernia, it’s a physical examination hernia. Because we don’t do the orders, we don’t believe that it’s worth it. And having said that, passing the medical questionnaire, the patient is, comes to show dice one afternoon before the operation is checked by his surgeon and any further discussion is done at that day. Patient are admitted following morning operation. One thing that’s different, it doesn’t go back home in the same day, usually stay two to three days after operation. He is, if he’s flying or distant, it’s going to be three days if it’s close by, if he prefers to stay. Just today’s feeling while and that set two days

Speaker 1 (00:07:26):


Speaker 2 (00:07:28):

They love it. They love to stay

Speaker 1 (00:07:31):

Still have the, there’s stationary bicycles around. Cool. Can you explain that?

Speaker 2 (00:07:38):

So that’s very different from any hospital that I have been, first of all doesn’t appear a hospital. It’s a beautiful place outside and inside one of they try to get a good experience in all aspects that you need for healing. Their food is excellent full of nutrients and healthy, lots of fruits, vegetables they have to walk to have a dinner or breakfast and stimulates you to walk all the time. Theoretically you should walk have five to 10 minutes every hour after the first day of surgery, the first day of surgery and forward and the patients interact a lot. Sometimes they meet friendships for life. There are meetings of people that have been admitted at the same time, I should die, develop friendship and they meet after years and years and years and this is totally different. So patients have dinner or lunch or meals at the same place that the staff hospital is. It’s just a little separation because we are usually busily but we pass by and we talk and it’s a nice conversation. It’s a very interesting environment. I’ve never been working before in any place like that.

Speaker 1 (00:09:05):

And I understand you encourage the walking and the cycling and the pool table also because you’re bending and standing up and that

Speaker 2 (00:09:16):

Even stair, even the stairs there are they specifically designed, they are not as high and they are a little bit further away so you can move. It’s not that you need to move fast but moving we think that’s is beneficial for healing, like applying traction to the tissue. So you encourage them to heal

Speaker 1 (00:09:44):

That what the comment you made about the occult hernias is right. I have a lot of patients that come to me from Canada and I try to encourage ’em to go to should eyes because of course it’s much more convenient to be close and I talk with Dr. Alexander about it because some of them have the symptoms, hernias and the imaging for hernia and on physical exam they don’t have an actual bulge but they have tenderness at the actual ring which is highly sensitive and Dr. Alexander explained to me that he does not or the nice hospital does not offer mm-hmm hernia repairs to that subset of patients that have symptomatic al hernias that are occult or hidden Because your data did not support repair those, your data showed that there they don’t have as high of a success rate after hernia repair. Is that correct?

Speaker 2 (00:10:37):

Yeah, no actually it’s not our data but these guys have more chronic pain than the other patients and then what we think the pain was never from the hernia as some people have big hernias and don’t have that much pain. So the, it’s concerning because if you have pain and the hernia that’s not detectable unless the femoral or the patient’s a little bit overweight something is a little different. Maybe water athlete’s hernia, like that’s a growing strain or growing pain but we don’t believe that’s related with the hernia itself. It’s our belief it still should be orally proofed but is what we think.

Speaker 1 (00:11:24):

And then when the patient comes who do they see before surgery the date? Let’s say they come from out of town. Do they see a somebody one or two days before the date of surgery?

Speaker 2 (00:11:39):

Usually they come straight to the hospital and they’re going to see their surgeon for sure. Eventually they see a family physician if is necessary. Most of the times if they sent the questionnaire and the referral from their family physician or internal medicine person that’s taking care of them is not necessary goes straight for the surgeon and then conversations are done about the procedure, what to expect, what the routine consent, sign it and go to their area. Enjoy a little bit please.

Speaker 1 (00:12:18):

One of the questions was it seems that some patients aren’t aware who their surgeon is until the day of surgery. Is that correct?

Speaker 2 (00:12:29):

Usually we know beforehand and the admission is done most of the cases for the, by the surgeon that’s going to perform the operation that will comprise maybe 90% of the patient that come from outside. It’s possible that sometimes like let’s say you are on standard for a surgery on Monday, your surgeon’s just going to see you on Monday morning earlier than the operation. Let’s start at 7, 7 30. So we are going to wake up very early <laugh> by the surgeon. You’ll see and see your hernia to review the papers.

Speaker 1 (00:13:08):

Okay. We have a lot of questions coming in for you when you already answered does size matter, so if there’s a golf ball size hernia or an inguinal squirrel hernia is there a certain size limit before you off offer a Shouldice technique?

Speaker 2 (00:13:26):

No, not really. We do Shouldice for a small and you do Shouldice for the hernia that go into the mid five. What may differ is if the patient can do that under our regular technique that’s sedation and the local anesthesia. Sometimes if it’s very big we recommend general anesthesia. We also do local in this patients as well to improve the <inaudible>, but the Shouldice technique can be done in all of them no problem. It’s say we have meshes there we can use, but for primary hernias we are going to use one in about 10,000. These are for patients that really when you pass these stitches in the teachers they tissues tear apart something that’s different. They inspected.

Speaker 1 (00:14:21):

So how often do you percentage wise, let’s say are the patients that come to see you for inguinal hernias? Mm-hmm How often do you use Mesh based repair?

Speaker 2 (00:14:33):

For primaries?

Speaker 1 (00:14:34):


Speaker 2 (00:14:35):

Rarely less than 1%.

Speaker 1 (00:14:37):

Less than 1% And for recurrent?

Speaker 2 (00:14:41):

For recurrent increases a little bit. So for recurrent is going to depend on what they find. Okay. It’s higher than 1%. Sometimes the patient have already a Mesh. Sometimes if the hernia is well adherent and most of the times when they have hernia the defect is very close to the pubic bone. Sometimes just reducing the hernia and covered with the same Mesh that they have is enough. So it’s going to depend on what they find. It’s a different ballgame when it’s a recurrence.

Speaker 1 (00:15:14):

Can you explain the difference in the repair if they have an inguinal, indirect hernia versus a direct hernia

Speaker 2 (00:15:24):

For us doesn’t matter too much because we visit all these spaces, we are going to check always for the space for the indirect and we are going to open this space for the direct because we are going to go prepared to new. Beside that, we check for femorals into different spots like from external part and when we open the posterior wall and we check also for interstitial hernias that are above the spermatic <inaudible>. So we always see all these spaces.

Speaker 1 (00:16:04):

And is there a difference in outcome for direct risk? Indirect,

Speaker 2 (00:16:07):

Not significant for us, not significant.

Speaker 1 (00:16:12):

And then what about femoral hernias? What if you find that?

Speaker 2 (00:16:15):


Speaker 1 (00:16:15):

Femoral hernia

Speaker 2 (00:16:16):

For femoral hernias is a little bit different so our procedure is not well established so we may use Mesh, we may use several different techniques even between all the surgeons there we may have different preferences is one of the things that I want to study in the next year. This year was a little bit different for the due to COVID we intended to see this year, but we are not going to be able to but something that we want to standardize, it’s not standardized, it’s going to vary a little bit from the characteristics of the patient and it’s going to vary a little also from the preference of the surgeon.

Speaker 1 (00:16:59):

The international guidelines recommend a posterior repair for femoral hernia, which is Mesh based. But as you know, Dr. Shouldice has described, he described his femoral hernia repair, tissue based repair and I’ve done it works very, very well for small hernias, small femoral hernias that are symptomatic. It’s different than the McVay repair, but the tissue that the suture he puts through the cooper’s ligament up to the inguinal ligament, leaves it un untied, does the Shouldice and then ties it down. That’s worked very well for I think for the smaller femoral hernia

Speaker 2 (00:17:44):

Varies a little bit. I like to do with Mesh the shouldice and also likes kind of tolerate or likes the use of Mesh. For femorals, sometimes it’s the only way to do it depends on the size of the space and the elasticity of the tissues. Yeah, but we are not able to say that we have one specific preferred technique is going to vary a little bit from surgeon to surgeon.

Speaker 1 (00:18:13):

Do you treat any sports hernias or athletic pubalgia?

Speaker 2 (00:18:19):

Usually we do the diagnosis or at least rule out a hernia. We may do the initial part of treatment but we send for other person to do the continuity because sometimes the first course of anti-inflammatories and rests and et cetera, physical measures doesn’t is not enough. So someone needs to follow them up and that’s not going to be us.

Speaker 1 (00:18:45):

We have some really great questions coming in. I have a whole bunch prepared for you, but a lot of ’em are being answered by these questions. What’s the chance of chronic pain or nerve entrapment with

Speaker 2 (00:18:55):

Repair? Yeah, chronic pain. That’s very important to discuss chronic pain right now because the concept that we classically researchers classically had of chronic pain is different from the new concepts that we are having from these studies around the world. Now what we had classically as chronic pain is that pain that imperial from most of activities you need to take medicines and the treatment for that is with a specialist and sometimes you take one year or more to get rid of the meth is what classically we understood this chronic pain but several articles around the world are showing that sporadic pain that sometimes we consider the post-op discomfort is higher than we thought. Classically we thought that was the post-op surgical pain would be around 1% for tissue repairs. That’s the classic information and the formation would be higher between five to 15%. Some of the times this pain would develop even one year or longer after as a result of the nerve entrapment by the hernia or contraction of the hernia causing nerve pain.

Speaker 2 (00:20:22):

So we still say that’s 1% or less than 1% but being honest can be smaller or higher. Pain that interferes with activity regularly is not frequent but occasional pain that goes away without medicine is a lot more frequent than we know that we thought. We are doing a study about that currently and how to consider that they have the pain but it’s not enough to trigger use of medicines or consult a physician and goes away by itself. So we are discussing that is a little higher than we thought, maybe 5%, but classical information tissue repair is related to 1% or less of chronic pain.

Speaker 1 (00:21:20):

Do you feel that the use of the steel instead of polypropylene suture or polyester suture is one of your secret sauces? In other words

Speaker 2 (00:21:32):


Speaker 1 (00:21:33):

A no inflammation associated with stainless steel.

Speaker 2 (00:21:36):

Yeah, yeah. Honestly when I start I didn’t like too much but now I think that’s just wonderful and I think that potentially decreases a lot the local inflammation. I think that can be one of the reasons because as a general surgeon, all of us once in a while will deal with a granuloma related with a prolene and there is no granuloma related with <inaudible>. That’s, yeah,

Speaker 1 (00:22:05):

Very unique. We used to

Speaker 2 (00:22:09):

Potentially can have a rule,

Speaker 1 (00:22:13):

I’m old enough to know have been taught how to do suture with steel for laparotomies and there’s a special technique to it. It destroys your fingertips for the larger ones, probably not for the what gauge,

Speaker 2 (00:22:28):

How is the very pain is okay,

Speaker 1 (00:22:31):

What cage do you use? What number steel do you use?

Speaker 2 (00:22:38):

Honestly we have the 32 and 34. I use the 32 even though it’s very thin, very delicate. Yeah.

Speaker 1 (00:22:47):

The bigger ones for the LA products used to really destroy your fingers, sign of a good version. Not like all these cuts, but yeah, I think that maybe part of it, I wonder if more of us should be using stainless steel. It’s just not as readily available anymore. It’s just not me. But you guys make it yourself.

Speaker 2 (00:23:06):


Speaker 1 (00:23:08):

Okay. Some more questions for you. There’s a question from our Facebook group which is do you remove Mesh or do you deal with best removal and the tissue repair at the same time?

Speaker 2 (00:23:18):

Depends. What’s the reason? There are different topics in removing Mesh. Okay. If the incisional hernia is a different topic, sometimes you have to take the Mesh to do your operation and in general less risk of removing the Mesh because we are not close to crucial structures as femoral vein or other nerves and et cetera. In case of the inguinal area we usually don’t do a removal of Mesh to treat chronic pain. If we are going to go for a recurrent hernia and there is a Mesh, if it was well implant and then was just lighting of the Mesh that caused the hernia, we sometimes even use the Mesh. If it not, that’s not the case. It’s causing any difficulty in the repair. Most of the times you can take it partially, it is very hard to take in their entirety because sometimes it’s close to the big vessels that are in the area. It can be done sometimes according with the case, but it’s not mandatory that you go when you do a recurrent hernia. We take out the previous Mesh.

Speaker 1 (00:24:44):

So just as overview, for those of you that are not familiar with the Shouldice hospital, it was developed based on the Shouldice Dr. Shouldice and the Shouldice technique, which is a purely tissue-based inguinal hernia repair. It is not a repair for ventral hernias, it’s specifically for inguinal hernias. And the philosophy of your hospital is to be able to do as much of your hernia repairs with the Shouldice technique as possible. Which is a non-measurable here. Yes.

Speaker 2 (00:25:16):


Speaker 1 (00:25:19):

Here’s another question. It’s a patient with bilateral al hernias for bilateral, would you repair both at the same time at the same surgery or what is your protocol for bilateral? So hernias are left and right.

Speaker 2 (00:25:31):

Yeah, the protocol for the hospital is to do at the same admission in different days. If the patient wants to be done at the same time, we can also do at one, send a patient home when he is healed do the other one. So this is a little bit of choice of the patient when the patient travel choose show dice, usually they want two done at the same time. So no we do, so then we do one side that’s most symptomatic first, wait one day patient feeling well go to the second side. One of the reasons we do local anesthesia as well and so if the local anesthesia will be a higher dose to do both at the same time, but we also as a philosophy of not doing too much tantrum at the same time. So both reasons. Anesthesia, local anesthesia and philosophy of doing less tension.

Speaker 1 (00:26:26):

Maybe you can explain your anesthesia protocol, which I thought was fascinating.

Speaker 2 (00:26:30):

Sure, sure. And that’s also very interesting. So in the past the patients were predominantly just local anesthesia, a little bit of sedation or sedation. We improved that. We have a local anesthesia with a long-lasting local anesthetic that can last until 18 hours and we have an intravenous sedition that’s kind of similar if we have the colonoscopy sedition, if you guys know, but kind of puts you off a little bit. Okay. Sometimes use lips, sometimes you don’t as far as the patient is comfortable, that’s okay for us. For the patient that are going for the second hernia, they are very confident. They don’t want too much sedation. They talk during the procedure we are discussing in talking. It’s very interesting And in the experience for them what’s the benefit of this kind of anesthesia? I would say that more than 95% of our patients walk from their operation table to their wheelchair outside the operating room.

Speaker 2 (00:27:35):

So the recovery starts right there and this has a stronger psychological effect. Everyone in all the team we understand that the patient’s under control of to start his or her recovery right there. So this is our preferential technique. Some patients need the general anesthesia and they go to general anesthesia if it’s necessary. But that’s our preference because it’s more physiologic. And having said that, we do patients with 9,000 years old. Okay, 90 is about every week that we do. Before COVID was every week we do patients with more than nineties and so we believe that this is very safe for them is the way that we think that’s should be done.

Speaker 1 (00:28:26):

Yeah, I remember because I met the patient at the <inaudible> hospital in the pre-op they were given some pills, which I think some pain pills, maybe some antibiotic and then they walked with the nurse into the operating room and I stood where the anesthesiologist would normally stand because this was all done under local anesthesia, which I also do. I do everything under local anesthesia by the United States. You still have an anesthesiologist which helps with some IV sedation even if you don’t do general anesthesia. And then when we were done, the patient got off the bed and walked back into the recovery into the couch or something. So that’s something you usually don’t see in the United States and it’s cool that you guys can do that.

Speaker 2 (00:29:18):

Yeah, I think that empowers the patient. That means that we are good to recover from now and they feel they like it. We love it.

Speaker 1 (00:29:28):

Okay, we So do you think that watchful waiting one of the questions is the patient has bilaterals but okay, they’re not that symptomatic. Do you feel that watchful waiting is a good idea in those patients and does it hurt their chance of being able to get a successful Shouldice repair if they do? Wait

Speaker 2 (00:29:48):

I think watchful waiting is a good idea. Mainly for patients that are not very physically active and et cetera. What I use, we used to say for the patient that do not have symptoms from the hernia, we explain what is watchful waiting and if they want to operate, we do operate if they want to watch, it’s okay to watch we to recommend a really watchful waiting or this for the patients with a very small hernias or with higher age or comorbidities associated comorbidities. So basically we explain that the risk of problems as incarceration is very low and it’s decision of the patient. If they want to go ahead, we go one or two sides. If they don’t it’s their decision.

Speaker 1 (00:30:43):

Looks like you have a, you’ve since in the past several years I’ve noticed that your hospital has been doing a much better job of outreach and there’s a Twitter page, Facebook page Instagram page for the hospital, which is nice. Yeah. And then I’ve actually had some answers to my questions on Twitter was so nice. But do you also make guarantees though in terms of outcomes?

Speaker 2 (00:31:16):

We give statistics guarantees in regard of outcome. I think no one can give but you are right. We are trying to and the COVID is there to help us. We need to improve our websites and et cetera. And then we are trying to be more interactive with our patients. I’m currently one of the surgeons that are designed to answer patients responses and et cetera and internet and et cetera. So yeah.

Speaker 1 (00:31:49):

Okay. The next question is again about Mesh and Mesh removals. So just to clarify specifically at the hospital you don’t do, are you trying not to do a lot of chronic pain patients? Yeah, that have Mesh problems or nerve problems that is not the specialty for your hospital. If they need a hernia repair and have maybe had a prior hernia repair, but it’s not complicated you will go in there and if the Mesh needs to be partially removed or fully removed, you may need to do that or you may incorporate the Mesh into the repair. But specifically just to clarify because there’s a lot of questions about and pain and form body reaction, ICE offers a very specific service and there are centers like mine that provide care for the patients that have a lot of hernia related complications. I think the Shouldice is not one of those in that they’re, what they do really well is offer tissue repair techniques, standardized repair, low inflammatory Shouldice techniques specifically. I mean if you want to get a Shouldice repair and you can go to the Shouldice clinic, that’s probably the best place to get it if that’s your best and best option. So I just want to clarify that

Speaker 2 (00:33:19):

For Yes, exactly. Shirin for example, we are not going to operate a patient re-op operate a patient for chronic pain. Okay? Currently we do not do that. In the past we we did some field, currently we are not doing that. If the patient has pain related to a recurrent hernia or cannot be said that’s due to the recurrent hernia or chronic pain and has a hernia and then we can operate him it’s not mandatory to take the hernia, sorry, the Mesh, if the Mesh is, doesn’t look like is a culprit of anything and is well incorporated to the patient’s tissues. There’s no suspicion that is going to be cause of anything. We don’t fool around if that one, but if it’s kind of loose, not helping, anything interfering with the repair would take it out. Just to clarify, most of the patients that they’re going to have a significant inflammatory reaction or if Mesh, they have the pain associated chronic pain so it’s a little different.

Speaker 1 (00:34:30):

And then let’s say the patient had all that, they had chronic pain, nerve entrapment and they’ve already had their Mesh removed and now they have a hernia recurrence. Would you treat that patient as one of the

Speaker 2 (00:34:45):

IT case that need to be discussed individually? If he has any potentially is a client for us but then the, it’ll be unlikely or difficult to do a Shouldice repair even though it’s not impossible. So need to be discussed the case by case because this will be an exception.

Speaker 1 (00:35:05):

Okay. Your tell me what’s been going on during this pandemic? Have you been open, are you practicing and have you changed your hospital length of stay or facilities to mm-hmm <affirmative> accommodate once you’re open.

Speaker 2 (00:35:23):

So we closed because we are just elective so we closed for two months and half about that. Yes, yes. We are reopening next Monday in different, actually you’re reopening for virtual consults this week I think Thursday, but for surgery on Monday and initially what we are taking all the precautions advised by the minister of health here we are going to restart with a very small number of patients, kind of 10 patients day. We usually do 30 patients day just to get everyone trained with their new precautions and et cetera. But so far we did not change length of stay and other measures they are going to be isolated, more frequent in the rooms. They are going to use masks if I walk in the building. But this is a work in progress so we may change during after few days so restarting Monday. So I’ll tell you <laugh> later how we are going to do.

Speaker 1 (00:36:36):

Sounds good. Yeah, that’s exciting that you guys are going to be back open. It’s been a while for all of us. Yeah. Can you elaborate on your anesthesia? What kind of anesthesia do you use for your local anesthesia and specific name and also does a patient have a choice as to which an anesthesia they can get?

Speaker 2 (00:36:59):

We proposed anesthesia is a local anesthesia. Usually it’s going to be more than 99% of the patients are going to receive rupi vaca because it’s longer duration and sedation varies. I beta according with the patient and according with anesthetist. But I would say that most of them will be based on the Milan and about choosing, let’s say a patient has prefers to go under general it’s not impossible but need to speak with the chief surgeon. Sometimes it’s just a phone conversation to justify to see can be for example for anxiety and for some patient with that have anxiety. It’s just really, really impossible to do something So it it’s sedation can be pretty heavy. The patient can sleep throughout the whole procedure with sedation. So it’s a discussion that’s going to be done. But our preferential method for operation is local anesthesia plus sedation because the patient start to recover immediately after it doesn’t have vomits. It is very rare. Nausea or vomit is afterwards can eat one or two hours after surgery.

Speaker 1 (00:38:17):

Can a patient choose which surgeon among your group they can have surgery with or is that assigned?

Speaker 2 (00:38:25):

Theoretically he can request. I would say that the rate of having the surgeon that you request is maybe 80% or more depending because of vacations and other things, but it’s close to 80%. The possibility of having the surgeon that you want in this site says that you are going to be assigned. But if you request it can be 80% but remind yourself that people that are there are there for long time have lots of experience.

Speaker 1 (00:38:57):

Of course, of course. And we talked earlier about not only are they there for a long time it’s very strictly regulated to make sure that the same mm-hmm technique is used for every single patient, which I thought was fascinating. I thought that was really good. Can you explain the technique very briefly? Everyone here really is a patient or future patient. Do you cut through all muscles and then can you also talk about the cremasteric muscle? That’s a question That was

Speaker 2 (00:39:31):

Okay, I’ll try to go slowly because I don’t know how much our patients are going to follow. So basically what happens as a repair, we are going through the tissues. We find the hernia being most commonly indirect or direct hernia. We isolate them and most of the times our push them push back inside the abdomen and then we continuing go through all tissues until we find the fat that’s just before the abdomen. That’s a deeper than most of the others hernia surgeons do that. They are more superficial. So we started from the deepest part, putting the tissues together. We do four layers of approximation of these tissues and we believe because we do four layers, we distribute better detention. In regard of cremasterics we had one article published long time ago showing that if we take the cremasteric muscles, cremasteric muscles are that muscles that may cause your testicle to come up when you are cold if you take them out, we are going to reduce a little bit more the chance of recurrence hernia because it’s with no go more the opening that the hernia can protrude the form and so that’s the standard.

Speaker 2 (00:41:08):

I have had some patient that requested specifically to do not take then in that case I did do not take, so depends on the patient, but the standard would be, should take it outer muscle.

Speaker 1 (00:41:23):

Thank you very much. That’s good clarification. Once you cut the muscle, you do suture it back up though. It’s you don’t leave it right,

Speaker 2 (00:41:33):

The grams. Yes. Yeah, we tie above and below. Yeah. Yeah.

Speaker 1 (00:41:38):

Okay. Another question for you. What do you do with the nerves during the surgery?

Speaker 2 (00:41:42):

Yeah, so that’s different as well because for the main nerves that we call ilio inguinal and ilio hypogastric, we try to see them and isolate them without cutting with. I say we try because there is significant anatomical variants sometimes you don’t see at all and sometimes due to anatomy you need to sacrifice. I mean cuts by sacrifice I mean cut the nerve because otherwise you cannot do the repair. So most of the times we are able to see and save the nerve. What it means that even if you have some problem with that nerve, this nerve is going to heal over time. Takes a long time because nerve heals a long in a long time but theoretically heals. There is one piece of nerve that we take is a branch of nerve that goes with the cremasteric that routinely if you take the cremasteric, we take this piece of the nerve that the genital branch of the genital femoral, that’s a, that will be the routine.

Speaker 1 (00:42:56):

Thank you very much for that. Another question, how long does a patient need to recover from your hernia repair? What’s your protocol for postoperative recovery and what they can and cannot do?

Speaker 2 (00:43:08):

So we are actually updating this protocol, but we encourage patients to walk in the same day of the operation in the first they pull up, we want them to walk five to 10 minutes every hour and there are stationary bikes without weights already in the lounge if the patients want to do, it’s not for racing, it’s just to move. Movement is good for pain is movement is good for healing in that view. We say that for most of the patients 15 days they can jog they can walk fast, jog very slowly or biking flat. The range for a limited amount of time for most of the patients. Pain being controlled, patient doing well in a month they can restart gym exercises of course we don’t want to restart that same level that they stopped one month ago. They’re going to rebuild slowly over the time. But we say that gym is about after one month. It’s a general statement.

Speaker 1 (00:44:11):

Is there anything you do not allow them to do?

Speaker 2 (00:44:17):

Sometimes we recommend, I had one <laugh>, he was a board builder and he wanted to change for a power lifting and he had bilateral direct hernias. Oh yeah. And he was kind of midway, mid 45 to 50. I said, oh my god, do you really need to do that because this kind of hernia come exactly from the weakness of tissues, the hernia that he had. So we cannot say should not do, but we advised that okay, you can do some weights, but do you need to go for power lifting? I suggest not.

Speaker 1 (00:45:03):

Yeah, it’s hard

Speaker 2 (00:45:05):

Power. Just to clarify, power lifting is that thing that you lift the most that you can once or twice it. It’s a significant amount of weight, a significant amount of stress in your body.

Speaker 1 (00:45:20):

Plus it’s not a smooth procedure either. They yank it up and they throw it down.

Speaker 2 (00:45:26):

Yeah, it’s a lot of training, a lot of straining. Yeah.

Speaker 1 (00:45:30):


Speaker 2 (00:45:30):

You change? I don’t think that anyone should do that even without hernia. No,

Speaker 1 (00:45:34):

I know I have the same about marathon running. But anyway, that’s a different story. Do you change your protocol in terms of the technique for women in any way?

Speaker 2 (00:45:45):

Yes it’s a little different because most of the times we are going to take what preserving meals, we preserve the vessels and the vast that goes from inside the abdomen to the testicles. So the testicles is still functioning and working and et cetera. And the meals, usually there is a ligament in that space. So usually or most frequently you take it and so it’s easier to close the posterior wall because there’s nothing there. So that would be the routine.

Speaker 1 (00:46:21):

And what do you do with the round ligament?

Speaker 2 (00:46:24):

We tie and

Speaker 1 (00:46:27):

Yeah, I do the same thing. The question is how my shouldice repair differ. I’m a purist. I try and do it as close to how it’s described as possible. The difference from, I also take the round ligament routinely in women. I think I do not take the hysteric muscle. That’s one thing that I do not do and I do not use stainless steel, but maybe I should. I should. Why do you think people don’t use stainless steel anymore?

Speaker 2 (00:47:04):

Commercial availability certainly is one of the reasons. Okay. Yeah. Also there is a curve for learning to use this stainless steel. It’s

Speaker 1 (00:47:13):

Not easy,

Speaker 2 (00:47:14):

But it’s not also that long. If you have experience in about one week, we are going to be very familiar with that. I agree. This curve is not just for the surgery surgeon, we need to have an assistant that holds it straight most of the time. So some it’s for implantation. So for implementing that, maybe take a little bit for people get used, but I really like how do we the final result of that. Yeah,

Speaker 1 (00:47:44):

Yeah, for sure. In residency, the United States, most countries outside of maybe some poorer third world countries where they’ve moved away from steel. Steel is very cheap. Among all the different suture materials, it’s cheaper than the polypropylene and ethibond the bond and different polyester braided sutures, those are actually quite expensive because there’s a whole process to make those through resins and braiding and so on. But it’s very easily available, easy to store, easy to use. So most countries that are developed don’t use stainless steel much anymore. And the bigger ones, the bigger sutures that we use for abdominal wall, they used to tear, they used to break and that break-in could cause some symptoms sometimes, which we don’t see the difference between steel and the other sutures is steel has zero give. There’s no stretching with steel. So even though it’s good in that there’s no inflammatory response, it doesn’t stretch at all. So in the thought in making the newer suture that there’s a little bit of stretch in those and so there may be less stiffness. The people that were getting their laparotomies done with steel had a lot of stiffness in their abdominal wall and if there was any extra movement of the abdominal wall, that suture would break. Do you see breakage of your sutures? Sometimes

Speaker 2 (00:49:14):

In reoperation, sometimes we do not. We are going to reoperate for other reason. For example, sometimes we do not find exactly where the sutures were placed. So it’s so well incorporated that usually we don’t, are not too concerned about the braking even if we use the thinner stitches because these are four layers, so we divide the tension. So no, I would say that breaking the stitches not really a concern.

Speaker 1 (00:49:49):

Okay, good. What if you have a patient that comes to you very complicated and that patient already has a known reaction to different suture materials but not steel. Would you use still use steel? Do you think that’s a good option for that patient?

Speaker 2 (00:50:08):

Yes because <laugh> very hard to have any reaction to Stuart. So yes, for this patient will be probably one of the best options.

Speaker 1 (00:50:20):

Let’s see. Here’s another question. This is for both of us. It looks like 43 year old male, excellent health active, 15% body fat six foot tall. So this patient has bilateral inguinal hernias and has been reading a lot online and seeing. So let’s see what the question is. He is convinced he should go with a pure tissue repair. Do you Dr. Spencer Netto, do you feel the Shouldice is the optimal choice and why do you feel that it’s superior to a Mesh repair for all hernias?

Speaker 2 (00:51:01):

Well we believe that in general for first time hernias tissue repair, if any repair that can give you 1% recurrence, one to two like ours, it’s great. So if that a tissue repair, we have the smaller amount of chronic pain possible, that’s the case of the tissue repair repairing compared to if Mesh repair, that would be a great repair for a young, relatively young and active man. Yes, my answer is short dice will be very adequate for this patient.

Speaker 1 (00:51:41):

Do you ever offer a McVay or a Bassini or any other type of tissue repairs

Speaker 2 (00:51:49):

For inguinal nose shouldice is going to be our preferential. Even for recurrences. If we do a recurrence and we know that’s going to be a good result, we feel confident in the final of the operation if you can do a show dice repair. So it’s one of measures that the hernia was a good one, like recurring hernias can be challenged sometimes and if you can do a Shouldice repair, you think, no, that was a very good repair.

Speaker 1 (00:52:18):

So the same questions asked to me, if I feel the Shouldice is superior obviously I offer all types of tissue repairs. I’m not contractually bound to do the Shouldice repair. So I do offer the Bassini and the McVay, but the Shouldice is my go-to tissue repair. It’s my preferred one. If the patient is a good candidate for it, I would choose that. Sometimes I feel you need really good tissue and you don’t want it to be under too much tension and of course it doesn’t address a femoral hernia, so it wouldn’t be a good option for that. I also offer the oust, which is a posterior repair, which I can do either open or robotically. So I think of all of those, the Shouldice has been proven study, Afro study to be superior. That said, as hernia surges, we feel that your surgeon should be the one that determines what is the best repair in their hands. So for example, maybe someone does a better Bassini than a Shouldice or better or does a due repair, you shouldn’t force your surgeon to do a Shouldice because that’s a highly technically advanced procedure and you have to disrupt the muscles to repair the muscles. So you don’t really want someone who hasn’t done it before or is unclear about the specifics of that repair to undergo it

Speaker 2 (00:53:43):

And being very clear and honest. If you use Mesh tissue repair, the difference for most of the patients is going to be new statistics because even any hernia repair that is done in good hands is going to be MI more than 95% chances of going completely. So the difference is going to be statistic. If you’re going to have one recurrence every a hundred patients, one and a half, two,

Speaker 1 (00:54:15):

And then we’re almost done in time flies so quickly

Speaker 2 (00:54:21):

You and we are having fun.

Speaker 1 (00:54:22):

Yes, exactly. Give me a little bit of insight as to the other hernias that you all repair and if there are options for laparoscopic repairs as well at the hospital.

Speaker 2 (00:54:37):

Currently we are not doing laparoscopics, but it’s a matter of debate to, I personally believe that we are going to move for that at some point, but currently not. We had some few discussion, we are returning to doing incisional. We stopped for a while to doing incisional or we had a long list of incisional and then we stopped to booking new incisional because we had one year list of incisional to do. So we stopped booking a new restart, your booking, and then COVID comes. So incisional, we don’t do the giant incisional or inpatient with significant comorbidities because we’re a small host, we don’t have ICU. So if you think that the patient is not going to have some difficulty breathe or has already any significant health problem, so that’s not the place for them to be done. We are going to refer to another hospital and currently we just do open, we don’t do laparoscopic. We are discussing what’s going to be done in the future. Several surgeons favor that you should offer as well. But we used to discussing.

Speaker 1 (00:55:46):

Yeah, I think I’m glad that you guys are considering it, but it’s for sure a whole different level of preoperative evaluation. And on that note do you have a BMI cutoff, a cutoff of a patient’s weights before they’re eligible? I know that that’s the question that’s been asked

Speaker 2 (00:56:06):

For. That was a great question actually. We do a lot of rehabilitation and I was just discussing our, no, I was in the European virtual hernia meeting. I don’t know if it took part, but I took part one or two weeks ago.

Speaker 1 (00:56:21):

Yes, I was I virtually there. Yes. Yeah,

Speaker 2 (00:56:24):

I was virtual there and very interesting the Americans speaking about the BMIs. So ideally we are going to use a operate patients with the BMI very close to 25 unless they are body builders or muscular or something like that. Yes. And this is something that you really do. I have seen people losing a hundred pounds to go to an operation I have seen and that they just say to us even before the operation, now the operation is just a mere the tail. Now I’m feel so great. I’m not going to put that weight on again. And of course if you have all this you can obtain that much weight loss, the results probably are going to be greater, patients are going to feel better and physiological is going to be better.

Speaker 1 (00:57:16):

That’s pretty awesome. Yeah. It’s not common to have patients close to 25 BMI in most states in the United States. Yeah.

Speaker 2 (00:57:26):

Yeah. I thought because I saw the statistics and we are writing some few articles and there’s no one with BMI close to 25. Yeah, I couldn’t find any other place. Patients close to 25 and I cannot state that we have 25, but it’s very going to be very close to 25.

Speaker 1 (00:57:47):

Yeah. Yeah. That would be ideal. That makes the, it’s easier on the body of the surgeon too, because you don’t have to fight the patient’s body when you’re operating.

Speaker 2 (00:57:59):

I think that empowerment of the patient, that he has a role in the result of his operations, not just the surgeon is very important. If he’s not, does not have the ideal BMI, the result may not be as good. He’s going to increase the incidence of complications, the incidence of infection, and eventually recurrence as well. Absolutely. I think a very important rehabilitation.

Speaker 1 (00:58:31):

Yeah, absolutely. Absolutely. The recurrence is a huge issue. Well, we are out of time and I’m out of my cough syrup, so you Thank you Dr. Spencer. It was really a pleasure. I hope to see you soon either at a conference or I will have to make another trip to the hospital

Speaker 2 (00:58:52):

To see you. Thanks. Coming the summer to see the flowers. It’s beautiful outside. It’s

Speaker 1 (00:58:57):

Gorgeous. Beautiful. And I’d like to say thank you and as a party

Speaker 2 (00:59:03):

Taking part of this.

Speaker 1 (00:59:04):

Thank you. So as all of you know can follow me this has been Simulcast on Facebook Live. So if you go to my Facebook page, Dr. Towfigh, you will be able to watch this in his entirety if you miss any of the sessions. I will also take this and post a link to it on my YouTube channel and I’ll link it to all the other forums. Thank you again, Dr. Spencer Netto, you’ve been amazing. We had a record number of questions submitted before, so I had literally 20 slides for you and we had 29 questions that we went through on Zoom and I think we had had something like 50 comments on Facebook already. So thank you doing what you’re doing. I hope to see you soon and everyone would be safe. Until next Tuesday, we’ll have another guest on Hernia Attack Live. Thank you very much. Thank you, Frank. Bye.