Shouldice Hernia Centre

Shouldice Hernia Centre is a hospital in Thornhill, Ontario, Canada, that is known for its specialization in external abdominal hernia operations. Shouldice uses a natural tissue, tension free, technique developed during World War II by Dr. Edward Earle Shouldice. Their ten full-time surgeons perform over 7500 hemiorrhapies each year. The facility, includes an administrative building which looks much like a southern mansion and a hospital wing designed specifically to meet the needs of hernia patients, is purposely comfortable, featuring a 23-acre (9.3 ha) property. Shouldice is a green facility with hot water and cooling systems powered by solar energy. The centre is owned by Shouldice Hospital Limited.

The facility was subject of a 1983 business case by the Harvard Business School. Written by professor James Heskett, the report is currently the school's fourth-best-selling business case, selling nearly 260,000 copies. Twenty thousand students at 500 universities worldwide read about the centre annually, as part of their curriculum.

Shouldice launched a website in 1995. Over 300,000 visit the site each year; each year, over 2,000 operations are scheduled online, and close to 10,000 emails requesting information are received.

The process

Pre-surgery

Shouldice requires patients to be at an acceptable weight appropriate to their height. Prospective patients who are overweight must bring down their weight to a level appropriate for the surgery. Shouldice states that it improves outcomes and has a full-time dietician on staff to help patients achieve their weight goals with guidance and special diets.

Patients enter the hospital the day before surgery and are given a briefing about the procedures to be followed the next day. The night before the operation is also intended as an opportunity for patients to come to know each other: Shouldice encourages patients to work together to promote recovery.

Doctors from other institutes constitute a disproportionately higher percentage of patients (doctors from the US needing surgery disproportionately go to Shouldice).^{[citation needed]}

Surgery

Shouldice operations normally take 35–40 min. Local anesthesia is used in most surgeries, instead of general anesthesia, as the latter is unnecessary in most types of hernia surgeries, and the former is both safer and less expensive. General anesthesia is used when necessary in certain specially scheduled cases. The procedure most commonly used at Shouldice is a natural tissue, repair of the abdominal wall anatomy and uses no artificial, surgical mesh.

Most surgeries at Shouldice involve reestablishing natural anatomic integrity by sewing muscle layers together in an overlapping fashion to repair the hernia defect. This specific technique is often referred to as the Shouldice operation or the Canadian operation.^{[citation needed]}Shouldice states that their complication rates (0.5%) are lower than rates achieved in general hospitals, described in The New England Journal of Medicine, April 2004 Vol. 350, No. 18, 33.4% for open mesh repairs and 39.0% for laparoscopic repairs of hernias.

Recovery

Unlike many hospitals, Shouldice does not have a "fleet of wheelchairs and gurneys, armies of aides to push them, and banks of wide elevators."^[1] Instead, carpeted floors, low-rise stairs and beautiful grounds are available, encouraging activity. The Shouldice property comprises 23 acres (93,000 m²), with a greenhouse, putting green, sunrooms, pool table and dining hall. The hospital focuses on patient care, without compromising on speedy recovery.

The landscaped grounds, pool table, and putting green are all intended to encourage patients to be mobile following surgery: to take walks in the grounds and to stretch and bend while playing pool or practising putting. Similarly, there are no television sets or telephones in patients' rooms and beds have to be adjusted manually. A daily exercise program is also provided. Patient participation in their own recovery program is a corner stone of the Shouldice philosophy.

Patients are scheduled to stay in the hospital for two days and three nights following surgery, although those who live locally and recover faster may leave earlier, if discharged by a surgeon after examination. In other hospitals the sort of low-risk patients that Shouldice operates on are sent home the same day without overnight hospitalization.

All rooms are double occupancy, and regularly flow through patients. The patient rooms have "low capital investment"—with no phone, television, and minimal medical equipment. Patients are essentially healthy people with a physical defect, which Shouldice cures. Therefore they are not treated as "sick" people but more as clean surgical patients who benefit from professional post operative and specialized care. The double occupancy rooms also provide income to cover costs not covered by the ministry of health in the global hospital budget. These essential charges are not covered by public health insurance. Shouldice is not, however, an example of the upper tier of two-tier health care as no patient is turned away because of inability to pay.

Follow-up

Shouldice sends out a newsletter to all available patients every year. The newsletter includes a questionnaire for Shouldice's post-operative follow-up program. The program is considered the world's largest and longest-running follow-up program, having been in place for over 65 years with an average mailing of over 100.000 per year. The post-op is gradually transistioning to e-mail, as much as possible.

Shouldice reports that fewer than 1% of patients have a recurrence after primary hernia repair. This compares to the 10-15% in normal hospitals.^[2] However, given that Shouldice does not perform surgery on patients weighing more than acceptable weight who are at greater risk of recurrence, meaningful comparison with other hospitals is not simple.

Studies carried out outside Shouldice generally show recurrence rates for "Shouldice repairs" (described above) which are higher than the recurrence rates reported by Shouldice, which demonstrates the importance of high volume experience in surgery. For example, a French study^[3] of 1,706 repairs performed using the Shouldice, Bassini's, and Cooper's ligament repairs found that Shouldice repairs had the lowest recurrence rate, but that the rate was 6.1% after 8.5 years. However, the surgeons performing the repairs in these studies are almost certainly less experienced with this type of repair than Shouldice surgeons. For example, in the French study, fewer repairs were performed over six years than would be performed in about three months at Shouldice.

Shouldice held annual patient reunions for 50 years, which one year attracted 1500 former patients. Reunions have been temporarily discontinued.

Primary staff

• Byrnes Shouldice, co-owner, president, chairman, former surgeon at the facility
• Germaine Urquhart, co-owner, vice president
• Daryl Urquhart, director of business development and grandson of the founder
• Shelley Shouldice, program coordinator, granddaughter of the founder

• Dr. Michael A. Alexander, MB, BS, FRCSC, FACS Chief Surgeon, Shouldice Hospital
• Dr. Cassim T. Degani, MB, BS, MS, FRCSC, FACS,
• Dr. Ram K. Singal, MB, BS, FRCSC
• Dr. Earle Byrnes Shouldice, MD
• Dr. Chin K. Chan, BS(Hon), MD, CM, CSPQ, DABS, FRCSC
• Dr. Richard T. Sang, MD
• Dr. Keith Slater, MD
• Dr. Rasheed. A. Affifi, MB, ChB, FRCSC
• Dr. N. Ross, MD
• Dr. Peter Kalman, MD, FRCSC, FACS
• Dr. Claude Burul, MD, FRCSC,
• Dr. Mohamed Ellabib, MD,
• Dr. David Smith, MD, FRCSC
• Dr. Ihap Guirguis, FRCSC, FRCS (ENG)

Notable patients

• Joe Clark, 1980s
• Jack Layton, mid-1990s
• Ralph Nader, mid-2000s

Trivia

• A season one episode of Monk featured the Shouldice grounds in exterior shots.
• Shouldice was used as the White House in the movie: Murder at 1600.
• A scene from Dawn of the Dead (2004 film) was supposed to be filmed on the grounds in August 2003, but was cancelled because of poor weather conditions and the Northeast Blackout of 2003.

Further reading

• Bendavid R, The Shouldice Repair. Inguinal Hernia Repair, eds: Schumpelick V, Wantz GE. Basel, Karger, 1995, pp 122-134.
• Bendavid R, E.E. Shouldice: A Biography. Problems in General Surgery, Vol 12, No 1, pp 1-5. Lippincott-Raven, Philadelphia, 1995.
• Bendavid R, The merits of the Shouldice repair. Problems in General Surgery, Vol 12, No 1, pp 105-109. Lippincott-Raven, Philadelphia, 1995.
• Bendavid R, Activity following herniorrhaphy. Inguinal Hernia Repair, eds: Schumpelick V, Wantz GE. Basel, Karger, 1995, pp 310-311.
• Bendavid R, Expectations of hernia surgery (inguinal and femoral). Principles and Practice of Surgical Laproscopes, ed. Simon Paterson-Brown and James Garden, W.B. Saunders Publishers, 1994 London, UK.
• Welsh D, Alexander M, The Shouldice Repair. Surgical Clinics of North America, Vol 73, No 3, June 1993, pp 451-469.

Notes

External links

• Shouldice Hernia Centre Site