Elective Herniorrhaphy Research Articles

Challenges of Anesthetic Management in Pediatric Patients with Hernia Inguinalis Lateralis Dextra Reponibilis: A Case Report

Introduction: Hernia inguinalis lateralis dextra reponibilis (HILD repr.) is a common condition in infants and children, but anesthetic management in these pediatric patients requires special attention. Children's unique physiological and pharmacological characteristics, potential comorbidities, and risk of postoperative pain demand a careful and integrated approach. Case presentation: This case report presents comprehensive anesthetic management of a 6-month-old male infant who underwent elective herniorrhaphy for HILD repr. The anesthesia procedure involved induction with sevoflurane and fentanyl, maintenance of anesthesia with sevoflurane, and multimodal pain management with paracetamol and bupivacaine. The surgery was successful without complications, and the patient recovered well. Conclusion: This case highlights the importance of implementing modern anesthetic practices in pediatric patients with HILD repr., including selection of appropriate anesthetic agents, close monitoring, and multimodal pain management. Specific challenges such as unique airway anatomy, variability in drug pharmacokinetics, and risk of perioperative complications are also highlighted. The successful anesthetic management of this case highlights the importance of an individualized approach and close monitoring to optimize clinical outcomes and minimize complications in pediatric patients with HILD repr.

Preliminary investigation and application of a modified objects memory test in perioperative cognitive evaluation.

To investigate the applicability of a modified verbal learning test redesigned from the memory subtest of the Syndrom Kurztest (SKT) in perioperative cognitive evaluation. Patients receiving elective herniorrhaphy and their accompanying family members (set as normal controls), 55-75 years old, were randomly divided into two groups. The two groups received the self-made objects memory test derived from the SKT (SMOT) SMOT or a traditional auditory verbal learning test (AVLT). The cognitive evaluation was administered at the bedside on the day before surgery and the second day after surgery. The SMOT test was administered to 121 subjects, while 107 patients received the AVLT test. After confirming that there was no significant difference in cognitive function between patients and their family members, the results of the SMOT and AVLT tests were compared. The results showed that the "low-score" ratio of the SMOT was significantly lower than that of the AVLT test (P < 0.05), and the influencing factors of the SMOT were less than those of the AVLT test. However, the learning effect of the SMOT was more significant (P < 0.05). This study preliminarily confirms that the SMOT has better applicability to elderly Chinese individuals than AVLT in perioperative cognitive evaluation, but its learning effect should be noted.

Clinical efficacy of an ultrasound-guided bilateral rectus sheath block for umbilical hernia repair in calves: A prospective randomized trial.

Surgical umbilical hernia repair is a frequent procedure in newborn calves, requiring mandatory pain management. This study aimed to develop an ultrasound-guided rectus sheath block (RSB) and to evaluate its clinical efficacy in calves undergoing umbilical herniorrhaphy under general field anesthesia. Gross and ultrasound anatomy of the ventral abdomen and the diffusion of a new methylene blue solution after injection within the rectus sheath were described in seven fresh calf cadavers. Then, fourteen calves undergoing elective herniorrhaphy were randomly assigned to receive either bilateral ultrasound-guided RSB with 0.3 mL/kg of bupivacaine 0.25% and 0.15 µg/kg of dexmedetomidine or 0.3 mL/kg of 0.9% NaCl (control). Intraoperative data included cardiopulmonary variables and anesthetic requirements. Postoperative data included pain scores, sedation scores and peri-incisional mechanical threshold assessed by force algometry at specific time points after anesthetic recovery. Treatments were compared using Wilcoxon rank-sum, Student's t-test, and Cox proportional hazard model as appropriate. Mixed effect linear models on rank, with random effect calf; fixed effects time, treatment, and their interaction were used to compare pain scores and mechanical thresholds over time. Significance was set at p = 0.05. Calves receiving RSB recorded lower pain scores between 45 - 120 minutes (p < 0.05) and at 240 min after recovery (p = 0.02). And they recorded higher mechanical thresholds between 45 and 120 min after surgery (p < 0.05). Ultrasound-guided RSB provided effective perioperative analgesia in calves undergoing herniorrhaphy under field conditions.

Appendix-preserving elective herniorrhaphy for de Garengeot hernia: two case reports

BackgroundEmergency appendectomy is often performed for de Garengeot hernia. However, in some cases, there may be a chance to perform an appendix-preserving elective surgery.Case descriptionA 76-year-old woman presented to our hospital with complaints of a right inguinal swelling, which we diagnosed as a de Garengeot hernia using computed tomography (CT). B-mode ultrasonography (US) of the mass showed an appendix 4–6 mm in diameter with a clear wall structure; color Doppler US showed pulsatile blood flow signal in the appendiceal wall. Twenty-eight days later, herniorrhaphy with transabdominal preperitoneal repair (TAPP) was performed without appendectomy. Another 70-year-old woman presented to our hospital with complaints of a painful bulge in the right inguinal region. The diagnosis of de Garengeot hernia was made using CT. B-mode US showed an appendix 5 mm in diameter with a clear wall structure. Color Doppler US showed a pulsatile blood signal in the appendiceal wall. Seven days later, herniorrhaphy with TAPP was performed without appendectomy.ConclusionDe Garengeot hernia is often associated with appendicitis; however, an appendix-preserving elective herniorrhaphy can be performed if US and intraoperative findings do not suggest appendicitis or circulatory compromise in the appendix.

Accidental Intrathecal Administration of Tranexamic Acid: A Case Report

Medication errorsare still one of the contributing factors leading to morbidity and mortality in anesthesia, despite measures to ensure patient safety. A 14-year-old male inadvertently received intrathecal tranexamic acid instead of hyperbaric bupivacaine for an elective herniorrhaphy. Shortly after induction, patient complained of severe back and lower limb pain, restlessness, tachycardia, hypertension, and generalized myoclonic seizures.

Evaluation of Effect of Preoperative Oral Carbohydrate on the Perioperative Agitation in Pediatrics Undergoing Elective Herniorrhaphy; A Doubl-Blind Randomized Clinical Trial

Background The aim of this study was to evaluate the effect of preoperative oral carbohydrate on the perioperative agitation in pediatrics with elective herniorrhaphy. Materials and Methods In this randomized clinical trial study, 120 pediatrics, 6 months to 10 years-old who underwent elective herniorrhaphy were admitted. Sixty pediatrics in the intervention group received 5 ml/kg of 20% dextrose solution manufactured by Samen Company as carbohydrate beverage exactly 2 hours before surgery and the control group (n=60) received distilled water. The perioperative agitation score was calculated as follows. Score 1: quiet, silent child, score 2: mild but agitated, score 3: medium aggression, and score 4: severe agitation measured before surgery, at recovery, 5, 15 and 30 minutes after intervention. Also, the incidence of nausea and vomiting was recorded in each group. Results Of the 60 pediatrics in the intervention group, 54 patients were quiet and silent at the time of entry into the operating room, and 6 patients had mild agitation; in the control group, 7 patients were quiet and silent, 41 patients were mild but agitated, and 12 were moderate. There was a significant difference in agitation between the two groups (P = 0.001). Five minutes after surgery, 54 patients scored 1, 6 patients scored 2 in the control group, 27 patients scored 1 and 33 patients scored 2. There was a significant difference between agitations of children 5 minutes after intervention in the two groups. Conclusion Five ml/kg of 20% dextrose solution as carbohydrate beverage exactly 2 hours before anesthesia may lead to parental satisfaction and improvement in positive behavior of pediatrics at anesthesia induction and wake up from anesthesia.

Efeitos do bloqueio peridural caudal em pacientes cirúrgicos pediátricos: estudo randomizado

BackgroundSurgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system. ObjectivesThe aim of this research was to determine the effectiveness of caudal blocks in intra‐ and postoperative pain management and in reducing the stress response in children during the same periods. MethodsThis prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient. ResultsChildren who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group. ConclusionsThe combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Effects of caudal block in pediatric surgical patients: a randomized clinical trial

BackgroundSurgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system. ObjectivesThe aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods. MethodsThis prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n=30) received general anesthesia and the other (n=30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient. ResultsChildren who received a caudal block had significantly lower serum glucose (p< 0.01), cortisol concentrations (p< 0.01) and pain scores 3h (p= 0.002) and 6h (p= 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group. ConclusionsThe combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Evaluation of efficacy of addition of dexmedetomidine in USG guided Transverse Abdominis Plane (TAP) block for postoperative pain relief in open unilateral elective inguinal herniorrhaphy: A prospective, randomized, controlled study

Evaluation of efficacy of addition of dexmedetomidine in USG guided Transverse Abdominis Plane (TAP) block for postoperative pain relief in open unilateral elective inguinal herniorrhaphy: A prospective, randomized, controlled study

Effect of Pre-Emptive Paracetamol Infusion on Postoperative Analgesic Consumption in Children Undergoing Elective Herniorrhaphy.

Studies have suggested that pre-emptive analgesia may decrease postoperative pain and opioid consumption. This study was undertaken to determine whether pre-emptive analgesia reduces postoperative pain and total paracetamol and opioid consumption in children undergoing herniorrhaphy. In this retrospective study, medical records were analysed before and after the pre-emptive analgesia regimen was introduced. Demographic data, perioperative drug consumption and discharge time were recorded. In the first group, no pre-emptive analgesia (NA; year, 2011; n=60) was given and in the second group, the pre-emptive analgesia (PA) paracetamol 10-15 mg kg-1 was given intravenously in the surgical ward at least 1 h before the surgical procedure (year 2013; n=60). Postoperative pain determining supplemental pain medications was scored using a Faces Pain Scale or visual analogue scale. Total paracetamol and opioid consumption during 24 perioperative hours was registered for all patients. The statistical analysis was performed using t test and Chi-square test. The mean age of children was 69.6±49.9 and 58.7±32.4 months (p=0.157), and the mean body mass index (BMI) was 18.3±8.8 kg m-2 and 16.4±3.7 kg m-2 (p=0.125) in the NA and PA groups, respectively. Total paracetamol consumption was 1157.8±908.8 mg vs. 983.0±536.4 mg (p=0.202), and the total opioid consumption was 5.8±4.7 in the NA group and 7.0±4.6 morphine equivalents in the PA group (p=0.160). No differences in the discharge time between the groups were observed (2.1±0.3 vs. 2.0±0.3 days, p=0.13). PA was proven to be efficient in the terms of postoperative pain control but did not reduce the overall analgesic drug consumption in the children undergoing elective herniorrhaphy. Multimodal pain treatment may decrease the consumption of analgesic drugs.

Efficacy of transversus abdominis plane block with dexmedetomidine mixed with ropivacaine for postoperative analgesia in pediatric patients

Objective To evaluate the efficacy of transversus abdominis plane (TAP) block with dexmedetomidine mixed with ropivacaine for postoperative analgesia in pediatric patients. Methods Forty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 1-4 yr, weighing 8-22 kg, scheduled for elective unilateral herniorrhaphy, were assigned into 2 groups (n=20 each) using a random number table method: ropivacaine group (group R) and dexmedetomidine mixed with ropivacaine group (group DR). TAP block was performed at the end of operation under ultrasound guidance, 0.125% ropivacaine 1 ml/kg was injected in group R and 0.075% ropivacaine plus 1 μg/kg dexmedetomidine was injected in group DR.A dose of morphine 0.05 mg/kg was intravenously injected when Face Legs Activity Cry Consolability score ≥4.The duration of postoperative analgesia and consumption of morphine within 24 h after operation were recorded.The development of nausea and vomiting, bradycardia, hypotension, respiratory depression, over-sedation and TAP block-related complications (hematoma or infection at puncture site, peritoneal puncture, local anesthetic toxicity) within 24 h after operation were recorded. Results Compared with group R, the consumption of postoperative morphine within 24 h after operation was significantly reduced, and the duration of postoperative analgesia was prolonged in group DR (P 0.05). Conclusion Dexmedetomidine combined with ropivacaine provides better postoperative analgesic efficacy than ropivacaine alone when used for TAP block in pediatric patients. Key words: Dexmedetomidine; Amides; Nerve block; Abdominal muscles; Child; Analgesia

Comparison of the effects of pretreatment intravenous fentanyl or intravenous lidocaine on suppression of fentanyl-induced cough in children: a randomized, double-blind, controlled clinical trial.

Background and aimThe injection of fentanyl usually causes coughing during induction of anesthesia. Based on a few studies about effects of lidocaine and the fact there is no study concerning the effect of fentanyl on fentanyl-induced cough in pediatric patients, the aim of this study was to compare the effectiveness of low dose of fentanyl with lidocaine in prevention of fentanyl-induced cough in children.MethodsThis randomized double-blind controlled clinical trial study was conducted at Motahari Hospital between February and August 2017 in Urmia (Iran). One hundred patients, aged 2–10 years, of class I or II ASA status who were candidates for elective herniorrhaphy under general anesthesia were enrolled in this study. They were randomly divided into three groups. One minute before the administration of 2 μg/kg fentanyl during induction of general anesthesia, Group I received 1.0 mg/kg lidocaine (n=33), Group II received 0.5 μg/kg fentanyl (n=34) and Group III received normal saline as a control group (n=33). The data were analyzed by STAT version 13. The incidence and severity of cough were determined across groups by using ANOVA and Chi-square tests. Multiple logistic regression was also used to examine the association between the outcome of cough incidence and clinical interventions as the exposures after adjusting for study covariates.ResultsThe highest incidence of cough was found in the Group III (54.5%) versus 32.4% and 21.1% in Group II and Group I subsequently (p=0.02). We have also found significant difference in the incidence of cough among group one and three (p=0.005), and among group two and three (p=0.045). No statistically significant difference has been detected between group one and two. The severity of cough was significantly higher in Group III compared to Groups I and II (p=0.01). The time of onset of cough was similar across groups. No side effects were reported after intervention in this studyConclusionThis study found that pretreatment with fentanyl 0.5mg/kg or 1mg/kg lidocaine is an effective approach to reducing the incidence and severity of fentanyl-induced cough in children.Trial registrationThe trial was registered at the Iranian Registry of Clinical Trials (http://WWW.irct.ir) with IRCT number: IRCT2016112027677N5.FundingThis study was not granted or funded by any institution.

Abdominal herniation associated with bullhorn injury as a separate entity from traumatic abdominal wall hernias.

Bullhorn injury is a rare mechanism causing traumatic abdominal wall hernia (TAWH). Bullhorn injury needs to be discussed as a separate sub-entity among TAWHs as the mechanism of injury is such that the great force is generated at a relatively small area of impact for a short duration of time which may lead to muscle defect without compromising integrity of overlying skin (referred to as sheathed goring) leading to herniation of abdominal viscera. The purpose of this review was to discuss abdominal herniation's associated with bullhorn injury as a separate entity from TAWHs; recognize the common presentations, mechanism of injury, and modalities of treatment currently utilized for this rare condition. A comprehensive online English, Spanish, Portuguese, and French language medical literature search was done using various electronic search databases. Different search terms including MeSH related to bullhorn-injury associated injuries including abdominal wall hernias were used. An advanced search was further conducted by combining all the search fields in abstracts, keywords, and titles. We summarized the data from the searched articles and found 12 cases who underwent emergency or elective herniorrhaphy with or without the use of mesh. We have proposed a treatment algorithm for such cases in light of the present era of laparoscopy and propose the usage of the term “bullhorn-injury associated traumatic hernia” for such cases. We present here the first most comprehensive discussion of all such cases reported till date.

Does Concomitant Organ Resection Compromise Elective Herniorrhaphy Results? An American Hernia Society Quality Collaborative Analysis

Penn State Milton S Hershey Medical Center, Hershey, PA; Vanderbilt University Medical Center, Nashville, TN

Incisional hernia: preliminary observations at a new institute

Background: Ventral hernia develops when an area of the abdominal wall weakens and develops a tear or hole. It may develop as a defect at birth, resulting from incomplete closure of a part of the abdominal wall, or develop where an incision was made during an abdominal surgery, occurring when the incision doesn’t heal properly. Incisional hernia is typically observed within the first 5 years after the surgical incision is made, but may develop long afterwards.1 This study was undertaken to review the history and clinical presentations in patients with incisional hernia, and subsequent treatment.Methods: In the present study, the first 20 cases of incisional hernia admitted to this institute for elective herniorrhaphy were studied. History of the previous surgery was obtained and the findings noted. Treatment carried out was included in the study.Results: Out of 20 cases, 12 were female (60%). Mean age of the patient was 41.9±11.9 years. Lower segment Caesarian section was the commonest preceding surgery (7 out of 12 females; 58.33%). Exploratory laparotomy accounted for 5 out of 8 cases amongst males (62.5%). Commonest site of the hernia was infraumbilical (n=9; 45%). Average size of the defect was 6.2 cm x 5.6 cm. 13 patients underwent surgery. Laparoscopic ventral hernia repair was the most common modality used (10 out of 13; 76.9%).Conclusions: Incisional hernia is more common in females, and gynaecological operations are most common cause and most common site is infraumbilical.

Comparison of muscular relaxation quality between the combination of remifentanil-atracurium and succinylcholine in rapid sequence induction and intubation

Introduction: Rapid sequence induction and intubation is the method of choice for anesthesia induction in nonfasted, full stomach patients in the operating room. The aim of rapid sequence induction is to quickly secure the airway to reduce the risk of regurgitation and aspiration of gastric contents. Succinylcholine, which is the most commonly used neuromuscular blocker in rapid sequence induction, has several side effects. The aim of this study is to compare the effects of succinylcholine and atracurium on muscular relaxation quality in rapid sequence induction and intubation. Materials and Methods: In this blinded, controlled clinical trial, seventy patients undergoing elective herniorrhaphy or orthopedic limb surgery randomly received one of the drug combinations, fentanyl/remifentanil/atracurium/nesdonal or fentanyl/nesdonal/succinylcholine and were evaluated for relaxation of the jaw muscles, vocal cord condition, and muscular response to intubation. Results: There was no significant difference in jaw relaxation, vocal cord condition, and muscular response to intubation between groups. Mean systolic and diastolic blood pressure and pulse rate were significantly lower in remifentanil-atracurium group compared to the succinylcholine group. Conclusion: Keeping the side effects of succinylcholine in mind, it seems that using remifentanil-atracurium combination for rapid sequence induction and intubation of the trachea produces results comparable to succinylcholine and consequently can be used as an alternative approach.

Changes in uncuffed endotracheal tube leak during laparoscopic inguinal herniorrhaphy in children.

The present study was conducted to investigate changes in uncuffed endotracheal tube (ETT) leak during laparoscopic surgery. The study included 31 patients aged between 1 and 6years scheduled for elective laparoscopic inguinal herniorrhaphy. Inspiratory and expiratory tidal volumes (TVi and TVe) were measured during mechanical ventilation, and ETT leak was calculated using the formula-ETT leak=(TVi-TVe)/TVi×100(%), assessed at the following time-points-5min after the start of mechanical ventilation (T1, baseline), just before the start of surgery (T2), 5min after the induction of pneumoperitoneum with 15° Trendelenburg tilt (T3), and at the end of surgery (T4). Additionally, leak pressure was assessed after successful tracheal intubation (T0, baseline) at T2, T3 and T4. Uncuffed ETT leak significantly decreased at T3 compared with T1 (baseline). Leak pressure significantly increased at T3 and T4 compared with T0 (baseline). Further studies are needed in order to determine whether the results are universal and associated with clinically significant outcomes.

The Effect of Preemptive Oral Celecoxib on Pain Reduction and Opioid Consumption during Elective Herniorrhaphy

The Effect of Preemptive Oral Celecoxib on Pain Reduction and Opioid Consumption during Elective Herniorrhaphy

Cost-effectiveness of inguinal herniorrhaphy at a tertiary care hospital

Background: To determine the cost-effectiveness of elective inguinal herniorrhaphy for various repair methods, and to compare between them in the context of reoperation.Methods: Retrospective review of medical records from patients who underwent elective inguinal herniorrhaphy during the period between January 1998 and June 2014. The incremental cost-effective ratios (ICER) of hernia repairs were calculated by using the primary tissue repair as reference cost.Results: There were 1,415 patients with 1,787 elective inguinal hernia repairs. Of the 1,787 repairs, 91.9% (1,643) were for primary and 8% (144) were for secondary hernias. Tissue repairs were performed in 64.9% (1,159) of all operations, open mesh repairs in 22.3% (399) and laparoscopic mesh repair in 16.7% (229). There were 137 reoperations (7.7% of 1,787), 125 (7.6% of 1,643) for primary repairs and 12 (8.3% of 144) for secondary repairs. Differences in the reoperation rates were greatest for the first 3 years of an operation, after which all the rates tended to converge. According to the Cox regression model, risk factors significantly associated with higher reoperation rates included direct hernias, longer duration of operation, and older age. The average cost of reoperation for tissue repair, open mesh repair, and laparoscopic repair were 10,500 (350 US$), 17,307.00 (576.90 US$), 21,631.00 (721.03 US$) bath, respectively. The incremental cost-effective ratios of primary OM and LAP were 134.11 and 181.12, respectively. The incremental cost-effective ratios of secondary OM and LAP were 91.99 and 139.14, respectively. Conclusions: Open mesh repair seem to be more cost-effective than laparoscopic hernia repair.

Chronic Antibody Refractory Pouchitis Associated With Abdominal Mesh in a 49-Year-Old Woman

Restorative proctocolectomy with ilealoanal pouch-anal anastomosis (IPAA) is the standard surgical therapy for patients with medically refractory ulcerative colitis (UC), UC with dysplasia, or familial adenomatous polyposis. Complications of IPAA are common and include chronic antibiotic-refractory pouchitis (CARP), which may lead to pouch failure. The etiology and pathogenesis of CARP are illdefined. A 49-year-old woman with IPAA presented to our Pouch Center in September, 2013 with worsening pouchitis symptoms including increased bowel frequency and abdominal pain. She was diagnosed with UC in 1984. She underwent proctocolectomy 2-stage IPAA for steroid-dependent UC in 1995. In 1997 and 2007 she developed a small bowel obstruction (SBO) requiring exploratory laparotomy, adhesiolysis and ventral herniorrhaphy. During the 2007 surgery, partial pouch prolapse with volvulus was noted, prompting sacral pouchpexy involving the small bowel mesentery. Postoperative pouchoscopy showed no active inflammation. In 2009, she underwent elective herniorrhaphy with abdominal mesh placement for incisional hernia. She subsequently developed recurrent pouchitis and cuffitis and initially responded to oral rifaximin. She then developed CARP without response to rifaximin, ciprofloxacin, budesonide or suppositories of belladonna/opium, tincture of opium and hydrocortisone/lidocaine. Abdominal imaging in 2013 showed bulging of the mesh containing unobstructed small bowel loops. Pouchoscopy in May, 2014 revealed chronic pouchitis with mucosal edema, ulcers, and pouch stiffness. Due to medical refractoriness and timing, we believed that her CARP resulted from herniorrhaphy with mesh placement. She underwent diversion ileostomy, adhesiolysis, and mesh removal in August, 2014. The pouchitis symptoms resolved without further medical therapy. She underwent ileostomy reversal in December, 2014 and was without clinical or endoscopic recurrence of pouchitis and has been doing well ever since. This is the first documented association of abdominal herniorrhaphy with mesh placement and CARP in the medical literature. Despite unclear pathogenesis, a variant of ischemic pouchitis due to chronic compromise of mesenteric blood flow or foreign body reaction is possible. Risks and benefits of herniorrhaphy with mesh placement in patients with ileal pouch must be carefully balanced.Figure 1Figure 2Figure 3