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 technique developed during World War II by Dr. Edward Earle Shouldice. Their ten full-time surgeons perform over 7500 hemiorrhapies each year. The facility, which looks much like a mansion, is purposely comfortable, featuring a 23-acre property. 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 1300 operations are scheduled online, and close to 10,000 emails requesting information are received.

In 2000, former Prime Minister of Canada Joe Clark revealed he had attended the facility in the 1980s.

During the 2006 federal election campaign, New Democratic Party leader Jack Layton was criticized for attending the facility. As a critic of private healthcare, Layton was actually unaware that the facility was private.[1] The hospital is, however, a non-profit operation, and it has a virtual monopoly on hernia repair in Toronto (Layton is from Toronto). Additionally, the surgery is covered under provincial insurance in Ontario[2].

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The process

Pre-surgery

Shouldice requires patients to be at an acceptable weight appropriate to their height. Prospective patients who are overweight must lose weight.

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 (i.e. if a doctor from the U.S. needs surgery he goes to Shouldice).^{[citation needed]}

Surgery

At most hospitals, surgery takes 90 minutes^{[citation needed]}, but Shouldice doctors take simply 35–40 minutes. Local anesthesia is used in surgeries, instead of general anesthesia, as the second is unnecessary in hernia surgeries, and the first is both safer and cheaper. The procedure most commonly used at Shouldice uses no surgical mesh.

Most surgeries at Shouldice involve sewing muscle layers together in overlap. The specific technique is often referred to as the Shouldice operation or the Canadian operation.^{[citation needed]}

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, with a greenhouse, putting green, sunrooms, pool table, stables, and dining hall. The hospital focuses on customer service, 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.

Patients are scheduled stay in the hospital for two days and three nights following surgery, although those who recover faster may leave earlier.

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. The double occupancy rooms also provide income from additional charges for semi-private rooms. These mandatory charges are not covered by public health insurance and effectively make the Shouldice an example of the upper tier of two-tier health care – welfare recipients, for example, cannot be referred there.

Follow-up

Shouldice sends out a newsletter to all of its patients. 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. 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 hernia repair. This compares to the 10-15% in normal hospitals.^[2] However, a study published in 2005 by two Shouldice surgeons reports a recurrence rate of 8% after three years for mesh repairs. The study also found no effect of preoperational weight loss by obese patients (a Shouldice requirement) on recurrence rate.^[3]

Studies carried out outside Shouldice generally show recurrence rates for "Shouldice repairs" (described above) which are higher than the recurrence rates reported by Shouldice. For example, a French study^[4] 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.

The disparity between the rates claimed by Shouldice and published rates also may be due in part to differences in the length of the post-surgery period assessed. Shouldice does its first follow-up after 18 months. Yearly follow-ups are conducted after that, but there is doubtless loss of contact with many former patients who have moved. The average period since surgery in Shouldice's data may therefore be shorter than the periods in published studies.

Shouldice holds annual patient reunions, which one year attracted 1500 former patients.

Primary staff

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

• Dr. Cassim T. Degani, MB, BS, MS, FRCSC, FACS, Chief Surgeon, Shouldice Hospital
• Dr. Ram K. Singal, MB, BS, FRCSC
• Dr. Earle Byrnes Shouldice, MD
• Dr. Michael A. Alexander, MB, BS, FRCSC, FACS
• 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. Lisa Plow-Jarvis, MD
• Dr. N. Hadjis, MD, FRCS, FRCSC

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

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

1. ^ John E Martin, Command Performance. Boston: Harvard Business School Press. ISBN 0-87584-562-2
2. ^ Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science. New York: Picador, 2002. ISBN 0-312-42170-2
3. ^ G. Chan & C. K. Chan. A review of incisional hernia repairs: preoperative weight loss and selective use of the mesh repair. Hernia, 2005. 9 (1), 37-41 Abstract
4. ^ J. M. Hay, M. J. Boudet, A. Fingerhut, J. Poucher, H. Hennet, E. Habib, M. Veyrieres, Y. Flamant. Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients. Ann. Surg., 1995 (Dec);222(6):719-27. Abstract

See also

• Hernia
• Lichtenstein Hernia Institute
• Shouldice Hospital Site