A Surgical Assembly Line to Repair Hernias
09 May 2005
To ask what goes on at The Shouldice Hospital is like asking, "Is the Pope Catholic?" This hospital situated in Thornhill, near Toronto, is a world-famous center for the repair of hernias. But is its reputation as good as they say? If so, why? And why is it possible for surgeons to repair an obvious hernia and miss another one? To find the answers I observed Dr Casim Degani, chief of surgery at Shouldice, perform one hernia operation after another.
A hernia is a protrusion of bowel through the abdominal wall. There are various types of hernias and 90 percent occur in men.
The Shouldice success rate is outstanding, virtually 100 percent if there’s been no previous surgery and 98 percent if it’s a repeat operation. The recurrence rate in other hospitals is 10 percent or more.
So what’s the secret of Shouldice success? First, its surgeons are excellent technicians. Good hands mean precise, speedy surgery. Then, the old story that "practice makes perfect" whether you’re a plumber or a surgeon increases the odds. Every day 35 hernias are repaired at the Shouldice Hospital. Talent and practice are a tough combination to beat.
Some patients are surprised that 96 percent of the time only local anesthesia is used at Shouldice for this 45 minute procedure. That’s because it works well and is less risky since many elderly patients are also suffering from cardiac irregularities, hypertension, heart failure, on anticoagulant therapy or have had a previous heart attack.
Local anesthesia, along with Valium and a painkiller, allow the majority of patients to walk away from the operating table. The result speaks for itself. During the last 55 years 290,000 hernia operations have been performed at the Shouldice with only one in 10,000 deaths within 28 days of surgery.
Recovery time is short. Patients leave the hospital in two days and return to
work usually within eight days. In fact, the recovery time of one male patient could surely enter the Guinness Book of Records.
Dr. Degani told me that one of his patients claimed his child had been conceived a day following the operation. His wife had arrived at the hospital quite concerned about her husband’s recovery. She obviously found out about it very quickly!
Apart from his athletic performance in bed, one patient played tennis within 10 days and another skied 11 days after the operation. How soon patients return to activity strictly depends on their own level of pain tolerance. This is because the surgical technique, along with the use of fine steel sutures, guarantees the hernia will not give way.
Should all hernias be repaired? Dr Michael Alexander at Shouldice referred to a six million dollar U.S. study that is currently trying to answer this question. But it’s his belief that not all small hernias require surgery, particularly in elderly patients if they’re not causing problems. But age itself is not a factor. His oldest patient was 99.
It was shocking to hear from Dr. Degani that in other hospitals it’s not rare for patients to have the main hernia repaired and return home with one that was not discovered and repaired. It’s hardly what one would expect to happen.
But Dr. Degani says that during a hernia repair at Shouldice 13 percent of the patients are found to have another hernia that was not suspected prior to surgery. These hernias are discovered because Shouldice surgeons do a layer by layer anatomical dissection searching for more than one hernia. These defects are repaired at the same time.
He says these hernias are missed in other hospitals because doctors fail to explore the entire anatomy during surgery. They worry they may damage the spermatic cord which can lead to injury of the testes and legal action. It’s another example of how fear of legal action results in a less than perfect procedure.
As I left Shouldice I remembered a remark made by a Harvard professor. He remarked, "To be a success in surgery you have to learn to do one operation well". For this reason people come to Shouldice Hospital from around the world. To be sure, the process is an assembly-line to repair hernias. But wow, what an assembly line!
