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It's a growing trend in U.S.:
Get it done better up there
of TheColumnists.com
AS SOON as I felt the tiny
bulge in my groin, I suspected I had a hernia. I knew it would
get bigger, and that surgery was the only option.
And I knew I would be going to Canada for my operation.
Eyebrows rose when I told friends I was going to a center outside
Toronto called Shouldice Hospital. The 89-bed facility does operations
for only one problem: a hernia.
"Are you crazy?" my friends said. "You don't have
to go out of the country to get a hernia fixed."
They were right. Hernia repairs are usually done as an outpatient
procedure. The surgeon makes an incision in the groin--the most
common hernia site--and puts back a loop of intestines that has
pushed its way through a weakness in the abdominal wall.
But I knew a number of people who had been disappointed by their
surgery. I had visited Shouldice more than 20 years ago to do
a story, and I came away impressed. I decided that now that I
was going to be a patient, Shouldice was the place I wanted to
try.
Doctors at Shouldice say hernia surgery is not always expertly
done. The anatomy is complex. When a repair is done poorly, recovery
can be long and painful. And the hernia can recur.
Shouldice has brought the specialty concept--practiced in complex
operations like open-heart and brain surgery--down to the level
of the lowly hernia. The hospital's 11 doctors have made hernia
repair their life work
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"Doing a single procedure and repeating it with high frequency allows you to become a perfectionist," says Dr. Michael Alexander, who fixes about 700 hernias a year. His total of 19,000 repairs over the past 24 years makes him one of the world's most prolific hernia surgeons. Some at Shouldice have done as many as 33,000 operations.
A favorite question is: "Don't you get bored to death?" Dr. Richard Sang, who has done 10,000 repairs, insists it remains a challenge--because no two hernias are quite the same. In each case, he said, the placement of nerves, the size of muscles, and the makeup of tissue are different. He somewhat lightheartedly compared the procedure to snowflakes.
"From the outside they all seem the same," Sang said. "But if you look closely, you see that each is different."
Each surgeon repairs three to four hernias a day--about 60 a month--more than most general surgeons do in a year, according to Daryl Urquhart, the hospital's spokesman. Most experts judge success by the absence of recurrence. Since 1945, Shouldice says, it has done more than 270,000 cases, with a reported recurrence rate for hernias of the groin of less than 1 percent.
Shouldice operates on all types of hernias: incisional (one that pushes past a surgical incision), epigastric (above the navel), umbilical (at the navel) and femoral (just below the groin). But hernias of the groin (called inguinal hernias) account for 80 percent of the total.
Urquhart says the recurrence rate is 10 percent for groin hernias when the procedure is done by general surgeons. That's a number disputed by others, including Dr. Karl A. LeBlanc of Baton Rouge, La., the president of the American Hernia Society, who puts the U.S. rate between 3 and 5 percent.
But both Urquhart's and LeBlanc's figures are estimates. There is no clearinghouse for results of hernia operations.
"If you look at the outcome of experienced surgeons with a special interest in hernia operations," LeBlanc said, "I think you would find it is comparable to those at Shouldice."
Nevertheless, LeBlanc says, the Hernia Society recognizes that the Canadian center has had "a long and impressive history. It has been the leader and shaker in the world of hernia repair."
The late Dr. E. Earle Shouldice started his hospital in 1945, at a time when he felt hernia repairs were poorly done. He set out to improve results, first, by insisting that patients shed excess weight (because fatty tissue makes a poor anchor for stitches); second, by developing what he felt was a nearly fail-safe repair technique. The operation is intended also to strengthen the abdominal wall.
Hernias can occur over time due to stress and strain on the abdominal wall, but they can also be present since birth. When the muscles of the abdomen become weak or slack, tissue, most commonly intestines, can force their way through a weak point. A hospital spokesman said a secondary weakness is found in 16 percent of cases.
In the Shouldice technique, a surgeon makes a 5-inch incision, then separates the layers of abdominal muscles and puts the bulging intestinal loop back where it belongs. The surgeon then overlaps each muscle layer by about half an inch and sews them together with one continuous stitch of stainless steel thread.
During the 1960s to the 1980s, many general surgeons started adopting the procedure that came to be called the Shouldice or Canadian method. However, many could not duplicate Shouldice's success rate--because the operation is difficult to master without specializing in it--so they switched to a simpler technique that implants a mesh screen or plug over the weak spot in the abdomnal wall.
The device, which holds back the hernia like a tire patch, has now become the most popular method. But debate continues over which is the better approach.
Shouldice, 20 miles north of Toronto, actually looks more like a resort hotel or spa than a hospital. It is a three-story building set amid 20 acres of manicured lawns and gardens. Thirty patients a day check in. On day one, they are examined. Day two is for surgery, using a local anesthesia. Days three and four are for observation and light calisthenics. And day five is discharge.
I arrived on August 28, a Monday. I had an electrocardiogram and blood work done and then was examined by Alexander, my surgeon. A jolly, soft-spoken man in his 50s, Alexander said he starts each day with his toughest case--and I would be his second. The first would be a woman who had had five recurrences--after surgery at other centers--and whose hernia had grown so large she looked pregnant.
Each year, 11 to 16 percent of Shouldice patients come because their hernia repairs performed elsewhere have failed.
On day two I was given a sedative, then taken to the operating table. I closed my eyes and fell asleep. Forty minutes later, the operation was over.
Back in my room, a nurse told me to sleep four hours, then to sit on the side of the bed for 20 minutes and try walking slowly around the room. When my feet touched the floor, I felt only a slight soreness around the incision. I got around the room with ease. So I continued out to the patients' lounge. There, my wife, Sara, was surprised to see me striding toward her. It was less than five hours since the surgery.
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For the next 48 hours I needed only extra-strength Tylenol as a pain reliever. On day five I was discharged and able to share the 200-mile return drive home.
Most patients I met left feeling positive about their experience. "I give Shouldice five stars," said Arnold Scolnick, a former dean of Manhattan Community College now living in Cocoanut Creek, Fla.
Ruth Ann Jackson, a retired teacher from Chatham, Ontario, went into surgery hunched over with a painful recurrent hernia. The next day she walked tall and pain-free. Two weeks later, she said she felt "excellent. As far as movement, I feel I can do anything. It was an incredible experience."
Movement is part of Shouldice's strategy to speed recovery. Patients have to go to a lounge to watch television or to make a phone call. Meals are served three flights downstairs in a cafeteria. There is a pool table (to promote stretching), a putting green outside (to get patients bending), and walking paths (to encourage strolling).
Each January, as part of a lifetime follow-up, Shouldice holds a reunion for patients in Toronto, where doctors check results. Patients who do not show up are sent a questionnaire, and Shouldice has used the results to compile what it says are the world's most extensive statistics on hernia repair.
The hospital charges $2,300, which includes the four days of hospitalization. LeBlanc of the Hernia Society says that in the United States, even though most hernia repairs are done as same-day surgery, the cost averages $4,000--in part, because of higher overhead and liability expenses--and up to $10,000 for laparoscopic surgery.
Some U.S. health insurers cover operations at Shouldice, although Medicare does not because it does not pay for elective surgery out of the country. Still, 6 to 8 percent of U.S. hernia patients cross the border--Ralph Nader was a recent patient--and others come from as far as Germany, Russia and China.
As for me, one week after surgery, I was able to drive 400 miles with my wife to Harriman, N.Y., where I spoke at the 50th reunion of my Columbia College class. Days later, I walked a mile through my beachside community of Point Lookout, N.Y., then swam briefly in the ocean. A month later, in October, I was on a golf course. But my biggest achievement came in November. I entered the Long Island Road Runners five-kilometer cross-country race and won the 70-and-over age group competition.
I'm back.
©
2001 by David Zinman. The
Zinman caricature is © 2001 by Jim Hummel. The photos are
from the Shouldice website.
You
can comment on this column or contact David Zinman with an email
to: talkback@thecolumnists.com
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