We don’t know exactly why people who had an inguinal hernia repair at the Shouldice Hospital had a much lower rate of surgery for recurrence than those who had hernias repaired elsewhere in Ontario. Ultimately, there are only 3 possible explanations: patient selection, surgical technique, or perioperative care. Most likely, it is some combination of these factors.
Dr. Vinden suggests that patient selection largely explains the difference, and he may be correct. However, for selection alone to account for the extraordinary difference in surgical recurrences we observed, the influence of selection must be enormous. Even assuming that 30% of all patients seen at the Shouldice Hospital are rejected for surgery and have their hernia repairs done elsewhere, the recurrence rate among those patients would have to be nearly 14% to mask a “true” risk of recurrence that is equivalent to the surgical recurrence risk in general hospitals.
It is true that randomized trials do not support the use of the Shouldice technique for inguinal hernia repair, especially when compared to modern, tension-free repairs. Like Dr. Vinden, we do not believe that general surgeons should stop performing their usual technique of hernia repair — with which they are most skilled and confident — in favour of a repair that is notoriously difficult to perform well in typical practice settings. We also agree that it is neither advisable nor feasible to regionalize a procedure as common as inguinal hernia repair to specialty hospitals.
On the other hand, it appears that much may be learned about inguinal hernia repair from large specialty hospitals — even if those lessons relate to issues such as how patient selection and preparation influence outcomes, and the value of focused expertise even in a relatively minor surgical procedure.