Umbilical hernia secondary to cirrhosis of the liver. Complications of surgical correction

Impact of nonmalignant ascites on outcomes of open inguinal hernia repair in the USA

PURPOSE

Studies on inguinal hernia repair in patients with ascites are limited, small, and inconsistent, exacerbating a challenging clinical dilemma for surgeons. To fill this gap in the literature, this retrospective cohort study used a national US database to examine the impact of ascites on the outcomes of open inguinal herniorrhaphy.

METHODS

Patients who underwent open inguinal herniorrhaphy between 2005 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Two groups were defined by the presence or absence of nonmalignant preoperative ascites. Ascites patients were propensity matched 1:10 with non-ascites patients. Surgical outcomes at 30 days for the matched groups, stratified by electiveness of procedure, were compared, with the primary end points of mortality and the NSQIP composite outcome "serious complication".

RESULTS

The study included 682 patients with ascites. Compared to matched controls, those with ascites had significantly increased odds of mortality (OR 3.3, 95% CI 1.5-7.0) after elective repair, but not after nonelective repair. Ascites was associated with increased odds of serious complication after both elective (OR 1.7, 1.2-2.3) and nonelective (OR 2.0, 1.3-3.0) surgery. Among ascites patients, age ≥ 65 years was associated with increased mortality (risk-adjusted OR 3.8, 1.2-14.4) and serious complication (OR 2.2, 1.2-3.9).

CONCLUSION

In this largest study to date on patients with ascites undergoing open inguinal herniorrhaphy, ascites increased the odds of mortality after elective repair and of serious complication after elective and nonelective repair. Age ≥ 65 was a risk factor for poor outcome. Inguinal herniorrhaphy is fraught with complications in this population.

Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease

INTRODUCTION

Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution.

METHODS

A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality.

RESULTS

One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038).

CONCLUSIONS

Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.

Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients

BACKGROUND

We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR.

METHOD

The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC).

RESULTS

A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02).

CONCLUSIONS

In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.

Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients

INTRODUCTION

The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites.

METHODS

Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival.

RESULTS

Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group.

CONCLUSION

Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.

Abdominal hernias in cirrhotic patients: Surgery or conservative treatment? Results of a prospective cohort study in a high volume center: Cohort study

Background

Surgical treatment of abdominal hernias in cirrhotics is often delayed due to the higher morbidity and mortality associated with the underlying liver disease. Some patients are followed conservatively and only operated on when complications occur (“wait and see” approach). The aim of this study is to compare outcomes of cirrhotic patients undergoing conservative non-operative care or elective hernia repair.

Methods

A prospective observational study including 246 cirrhotic patients with abdominal hernia was carried out. Patients were given the option to select their treatment: elective hernia repair or conservative non-operative care. Demographics, characteristics of underlying liver disease, type of hernia, complications and mortality were analyzed. During follow-up of patients who opted for the “wait and see” approach, emergency hernia repair was performed in case of hernia complications.

Results

Elective hernia repair was performed in 57 patients and 189 patients were kept in conservative care, of which 43 (22.7%) developed complications that required emergency hernia repair. Elective surgery provided better five-years survival than conservative care (80% vs. 62%; p = 0.012). Multivariate analysis identified multiples hernias [Hazards Ratio (HR):6.7, p < 0.001] and clinical follow-up group (HR 3.62, p = 0.005) as risk factors for mortality. Among patients undergoing surgical treatment, multivariate analysis revealed MELD>11 (HR 7.8; p = 0.011) and emergency hernia repair (HR 5.35; p = 0.005) as independent risk factors for 30-day mortality.

Conclusions

Elective hernia repair offers an acceptable morbidity and ensures longer survival. “Wait and see” approach jeopardizes cirrhotic patients and should be avoided, given the higher incidence of emergency surgery due to hernia complications.

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Prospective study comparing “wait and see” approach with elective surgical repair of abdominal hernias in cirrhotic patients.

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About 22.7% (n = 43) of patients under conservative treatment developed hernia complications requiring emergency hernia repair.

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Five-year survival was higher in elective repair group than in conservative treatment (80% vs. 62%; p = 0.012).

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Among patients undergoing hernia repair MELD>11 and emergency surgery were independent risk factors for 30-day mortality.

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“Wait and see” approach jeopardizes cirrhotic patients, as a high incidence of emergency surgery negatively impact survival.

Acute Abdomen From Umbilical Hernia Rupture to Flood Syndrome: A Case Report and Review of Literature

Flood syndrome is caused by spontaneous rupture of an umbilical hernia in a patient with tense, long-standing ascites. It is a rare complication of hepatic cirrhosis and has a high mortality rate. Flood syndrome is so named because a rush of ascitic fluid often follows the spontaneous umbilical hernia rupture. We present a case of a 39-year-old male patient with a history of alcoholic liver cirrhosis and recurrent ascites who underwent multiple abdominal paracentesis prior to developing an umbilical hernia that eventually ruptured, causing flood syndrome. The authors would like to discuss flood syndrome with a focus on management options.

The abdominal wall incisional hernia repair in cirrhotic patients

BACKGROUND

The incidence of abdominal wall hernia in cirrhotic patients with ascites is between 20 and 40%. Controversies regarding the treatment modality and surgical timing of abdominal wall incisional hernia repair in cirrhotic patients remain. The study proposed wants to analyze the abdominal incisional hernia repair in cirrhotic patients with ascites performed in a single center to determine post-operative morbidity, mortality and complication rate.

PATIENTS AND METHODS

Cirrhotic patients with abdominal incisional hernia that underwent surgical operation for abdominal wall hernia repair at the "Policlinico Paolo Giaccone" at Palermo University Hospital between January 2015 and December 2016 were identified and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and the surgical and ICU registries. The degree of hepatic dysfunction was classified using Child-Pugh classification. Post-operative mortality was considered up to 30-days after surgery. A follow-up period of 6 months at least was performed to evaluate hernia recurrence and complications.

RESULTS

Mortality rate is of 18.5% (p 0.002). Recurrence rate (p 0.004) and seroma formation rate (p 0.001) are most frequent in urgency group. The elevated ASA score and the prediction of a complicated post-operative course is higher in urgency group (p 0.004) as higher is the in-hospital stay (p 0.001) and the ICU stay (p 0.001).

CONCLUSIONS

Elective surgery for abdominal wall hernia repair in cirrhotic patients seems to be successful and associated with lower mortality/morbidity rate and recurrence rate than urgency.

Hernia Management in Cirrhosis: Risk Assessment, Operative Approach, and Perioperative Care

BACKGROUND

The rising incidence of liver disease has complicated the management of common surgical pathologies. Hernias, in particular, are problematic given the shortage of high-quality data and differing expert opinions. We aim to provide a narrative review of hernia management in cirrhosis as a first step toward developing evidence-based recommendations for the care of these patients.

MATERIALS AND METHODS

A literature review using separate search strings was conducted for PubMed and Cochrane Central Register of Controlled Trials databases. Review articles, conference abstracts, randomized clinical trials, and observational studies were included. Articles without a focus on patients with end-stage liver disease were excluded. Manuscripts were selected based on relevance to perioperative risk assessment, medical optimization, surgical decision-making, and considerations of hernia repair in patients with cirrhosis.

RESULTS

The existing literature is varied with regard to focus and quality of data. Of the 4516 articles identified, 51 full-text articles were selected for review. In general, there is evidence to suggest that individuals with compensated cirrhosis may successfully undergo and benefit from hernia repair. Patients at high risk for decompensated cirrhosis may be best served by nonoperative management.

CONCLUSIONS

Carefully selected patients with cirrhosis may proceed with herniorrhaphy. A multidisciplinary approach is essential to provide high-quality care and improve outcomes.

Sudden Death Due to Spontaneous Small Bowel Perforation within an Incarcerated Umbilical Hernia

Umbilical hernias are estimated to occur in up to 20% of patients with long-standing cirrhosis and ascites. Complications such as strangulation and infarction of the bowel or rupture of the bowel loops and/or hernia sac are uncommon but potentially life-threatening consequences. Often these events happen in association with abdominal trauma or after procedures such as paracentesis. Spontaneous rupture is more likely in cases where strangulation and subsequent necrosis of the bowel has weakened and thinned the incarcerated intestinal wall. We report a case of a 63-year-old male with a history of alcohol abuse complicated by cirrhosis and ascites who was found dead in his home approximately 30 minutes after last being seen alive. He was found at rest in a seated position without evidence of recent trauma. At autopsy, an ulcerated umbilical hernia was present containing a loop of perforated, necrotic small bowel. There was evidence of peritonitis including one liter of yellow-red fluid accumulation in the peritoneal cavity, multifocal areas of fibrinopurulent debris adherent to the small bowel, and a dull gray discoloration to the peritoneal lining. The case was signed out as death due to peritonitis and spontaneous perforation of small intestine due to strangulated and infarcted small intestinal umbilical hernia and the manner, natural. Although spontaneous perforation of the bowel within a hernia sac is uncommon, it may contribute to sudden death in patients lacking a history of trauma or recent medical procedures and physicians certifying these deaths should be aware of the possibility.

Incarceration of umbilical hernia: a rare complication of large volume paracentesis

We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present.

The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute

Purpose

Traditionally, the surgical repair of umbilical hernia in cirrhotic patients with ascites is avoided because of a significant recurrence rate and perioperative morbidity/mortality. However, recent reports recommend early elective surgery in these patients because surgery-related complications can be reduced with minimally invasive surgery and development of perioperative patient care. The current study was conducted to analyze safety and feasibility of umbilical hernia repairs performed in a single institute.

Methods

A single center retrospective analysis of patients' data was conducted. Eighteen patients with umbilical hernia accompanied by liver cirrhosis underwent hernia repair in the period between 2005 and 2012. The charts of these patients were reviewed and demographic data, postoperative complications, and recurrence were recorded.

Results

Eleven males and seven females with a mean age of 62.9 years were analyzed. Two of the patients were classified as Child's class A, 11 as Child's class B, and five as Child's class C. Four patients underwent emergency surgery because of perforations in the hernia sac in two cases and incarcerated hernias in the other two cases. Of the 18 patients who underwent surgery, four (22%) experienced a recurrence, three (17%) developed edema at the surgical sites, one (5%) experienced hepatic coma, and one (5%) showed postoperative variceal hemorrhage. All of these events occurred after emergency surgery.

Conclusion

In contrast to traditional concepts, early and elective repair of umbilical hernia can be performed easily and safely in cirrhotic patients.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

Risk of hernia incarceration following transjugular intrahepatic portosystemic shunt placement

PURPOSE

Hernia complications after creation of a transjugular intrahepatic portosystemic shunt (TIPS) have been reported, although the incidence of this complication is unknown. This study was designed to determine the incidence, morbidity, and outcome of hernia complications in patients with preexisting abdominal or inguinal hernias after TIPS creation.

MATERIALS AND METHODS

The medical records of 244 consecutive patients undergoing TIPS creation between 1999 and 2007 at a single institution were reviewed. The study population was 57 patients (23%) with a preprocedural abdominal or inguinal hernia. The investigated outcome was small bowel obstruction or postprocedural incarceration of a preexisting hernia. Demographic and procedural variables were evaluated for an associated increased risk of hernia complications.

RESULTS

Hernia complications developed in 25% of patients (14 of 57) after TIPS creation at a mean presentation of 62 days (range, 2-588 d). Thirteen complications (93%) required emergent surgery, of which four (29%) required bowel resection for necrosis. There were no resulting deaths. Ninety-eight percent of patients with a hernia complication had the procedure to treat refractory ascites. The indication of refractory ascites was significantly associated with the risk of a hernia complication (P = .002).

CONCLUSIONS

A 25% incidence of hernia complications following TIPS creation in patients being treated for refractory ascites is higher than expected; emergent surgery is required in most cases. Further investigation to formulate a plan for elective management is warranted.

Acute abdomen secondary to incarcerated umbilical hernia after treatment of massive cirrhotic ascites

Umbilical herniation is common in patients with liver cirrhosis and ascites. Rarely, they suffer from incarceration and strangulation of the umbilical hernia after treatment of ascites. We report 3 cases of umbilical hernia incarceration following removal of massive ascites with different treatment modalities. Physicians managing this group of patients should be aware of this rare and potentially fatal complication.

Emergency liver transplant in patient with Child-Pugh class C cirrhosis and strangulated umbilical hernia

The authors report the case of a patient who presented with small bowel obstruction while awaiting liver transplant for Child-Pugh class C cirrhosis. He underwent emergency liver transplant with resection of the small bowel after the obstruction did not improve with conservative management. The authors believe this is the first case of successful emergency liver transplant with resection of the small bowel in a patient with decompensated Child-Pugh class C liver cirrhosis and strangulated umbilical hernia. This case suggests the possibility of improved outcomes of emergency hernia repair in patients with liver cirrhosis when small bowel resection is combined with liver transplant.

Laparoscopic umbilical hernia repair is the preferred approach in obese patients

INTRODUCTION

The optimal method of umbilical hernia repair (UHR) in the obese population, laparoscopic vs open, is not standardized. The purpose of this study was to determine the optimal surgical option for UHR in the obese population.

METHODS

A retrospective chart review was conducted on 123 obese patients (body mass index [BMI] >30) who underwent UHR from 2003 to 2009 at a single institution. Patients were grouped by surgical approach (open vs laparoscopic). Intraoperative and postoperative courses were compared. Follow-up in the postoperative period was obtained from patient records and telephone interviews.

RESULTS

Of the 123 patients undergoing UHR, 40 and 83 patients were operated on with the laparoscopic and open approach, respectively. Patients were well matched by demographics as well as comorbidities. No difference in the mean BMI was shown between the laparoscopic and open groups (37 vs 35, P = not significant, respectively). The operative time was significantly prolonged in the laparoscopic group (106 vs 71 minutes, P < .01). Intraoperatively, no complications occurred in either group. In the immediate postoperative period, 1 patient who underwent laparoscopic UHR was readmitted for small bowel obstruction, and 2 patients in the open group were readmitted, 1 for pain control and 1 for wound infection. Follow-up was achieved in 63% of the laparoscopic group and 58% of the open group with a mean follow-up of 15 months in the laparoscopic group and 20 months in the open group (P = not significant). A significant increase in wound infection was reported in the open group with mesh insertion when compared with the laparoscopic procedure (26% vs 4%, P < .05, respectively). No hernia recurrence was shown in the laparoscopic vs the open group with mesh insertion (0% vs 4%, P = not significant, respectively).

CONCLUSIONS

In obese patients, the laparoscopic approach was associated with a significantly lower rate of postoperative infection and no hernia recurrence. Laparoscopic hernia repair may be the preferred option in the obese patient.

Hérnias abdominais e inguinais em pacientes cirróticos: qual é a melhor conduta?

INTRODUÇÃO: Tradicionalmente os procedimentos abdominais eletivos em pacientes cirróticos têm sido amplamente desencorajados graças à elevada morbi-mortalidade consequente às complicações da cirrose, descritas por diversos autores. Outros serviços, em contrapartida, obtiveram resultados distintos, advogando a favor de cirurgia eletiva. MÉTODOS: Uma revisão de artigos utilizando-se a palavras "abdominal wall hernia" e "cirrhotic patients" foi realizada na base de dados PubMed. Dos resultados obtidos, 28 artigos foram considerados para elaboração desta revisão. RESULTADOS: Pôde-se observar que a incidência de hérnias em parede abdominal é relativamente elevada em pacientes cirróticos, sendo que muitas delas têm evolução desfavorável e requerem tratamento cirúrgico específico. Com o advento do sistema de alocação de órgãos baseados no escore de MELD, muitos centros estão repensando suas condutas em situações como esta, dado que muitos dos pacientes em questão encontram-se em lista de espera para transplante hepático. Dessa forma a cirurgia eletiva tem conquistado maior papel no manejo desta condição com intuito de diminuir morbi-mortalidade nesses pacientes. Além disso, a qualidade de vida mostrou-se um importante fator a ser considerado, estando muito prejudicada nesta condição. CONCLUSÃO: Poucos estudos com grandes amostragens foram conduzidos até o momento e não há consenso sobre qual conduta é a mais indicada levando em consideração taxas de morbi-mortalidade.

Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy

BACKGROUND

Patients with umbilical hernias complicated by liver cirrhosis have an increased likelihood of complications following herniorrhaphy. The aim of this study was to investigate the clinical outcomes in patients with umbilical hernias complicated by liver cirrhosis.

METHODS

Between 2001 and 2010, 44 patients were enrolled in this study. The comparison between non-operative and operative group was performed. Patients who underwent emergency versus elective surgery were also compared.

RESULTS

Of the 44 patients, there were 33 men and 11 women. Thirty-one patients (70.5%) underwent surgery and 13 patients (29.5%) were treated conservatively. Overall morbidity and mortality rates following herniorrhaphy were 42% and 6.5%. The mean albumin level was significantly lower and total bilirubin, creatinine and mean model of end-stage liver disease score were significantly higher in non-operative group than in operative group. Combined resection was performed more frequently in the emergency group than in elective group. A significantly higher proportion of patients in emergency operation group had postoperative complications (P=0.01), especially ascites (P=0.02). The operative time and postoperative hospital stay were significantly shorter in the elective operation group than in emergency operation group.

CONCLUSIONS

Early, elective repair of umbilical hernias in cirrhotic patients should be advocated considering the hepatic reserve and patient's condition. Ascites control is the mainstay of post-operative management.

A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites

BACKGROUND

Patients with both cirrhosis and ascites have a 20% risk of developing umbilical hernia. A retrospective study from our center comparing conservative management of umbilical hernia with elective repair in these patients showed a significant risk of mortality as a result of hernia incarceration in conservatively treated patients. The goal of this study was to assess the safety and efficacy of elective umbilical hernia repair in these patients prospectively.

METHODS

Patients with liver cirrhosis and ascites presenting with an umbilical hernia were included in this study. For all patients, the expected time to liver transplantation was more than 3 months, and they did not have a patent umbilical vein in the hernia sac. The following data were collected prospectively for all patients: Child-Pugh-Turcotte (CPT) classification, model for end-stage liver disease (MELD) score, kidney failure, cardiovascular comorbidity, operation-related complications, and duration of hospital stay. Mortality rates were registered in hospital records and verified in government records during follow-up. Mortality rates were registered in hospital records and verified in government records during follow-up. On completion of the study, a retrospective survey was performed to search for any patients who met the study inclusion criteria but were left out of the study cohort.

RESULTS

In total, 30 patients (25 males) underwent operation at a mean age of 58 years (standard deviation [SD] ± 9 years). Of these 30 patients, 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C. The patients' median MELD score was 12 (interquartile range [IQR], 8-16). In 10 (33%) of the 30 patients hernia repair was performed with mesh. The median duration of hospital stay was 3 days (IQR, 2-4). None of the patients were admitted to the intensive care unit. Postoperative complications included pneumonia and decompensation of cirrhosis (1 case each,) resulting in prolonged hospital stay for those 2 patients. After a median follow-up period of 25 months (IQR, 14-34), 2 (7%) of the 30 patients died; neither of the deaths were attributable to the umbilical hernia repair. A total of 2 patients suffered recurrence.

CONCLUSION

Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites.

Umbilical hernia rupture with evisceration of omentum from massive ascites: a case report

Introduction

The incidence of hernias is increased in patients with alcoholic liver disease with ascites. To the best of our knowledge, this is the first report of an acute rise in intra-abdominal pressure from straining for stool as the cause of a ruptured umbilical hernia.

Case presentation

An 81-year-old Caucasian man with a history of alcoholic liver disease presented to our emergency department with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed with excision of the umbilicus and devitalized omentum.

Conclusion

We report the case of a patient with a history of alcoholic liver disease with ascites. Ascites causes a chronic increase in intra-abdominal pressure. A sudden increase in intra-abdominal pressure, such as coughing, vomiting, gastroscopy or, as in this case, straining for stool can cause rupture of an umbilical hernia. The presence of discoloration, ulceration or a rapid increase in size of the umbilical hernia signals impending rupture and should prompt the physician to reduce the intra-abdominal pressure.

Surgical repair of umbilical hernias in cirrhosis with ascites

The most common complications of umbilical hernias in patients with cirrhosis and ascites include leakage, ulceration, rupture and incarceration. If such a complication is present, there is a high mortality rate after surgical repair. Elective repair is the most effective choice, as it prevents complications with a lower mortality. However, the control of ascites before and/or after repair is mandatory but may not always be possible with diuretics and paracentesis. Portal decompression by transjugular intrahepatic portosystemic shunt (TIPS) with better control of ascites may allow these patients to undergo surgery. Patients with cirrhosis and umbilical hernias should be referred for consideration of an elective surgical repair with mesh, preferably after optimal management of ascites. There should be a low threshold for placement of a TIPS to facilitate surgery and reduce the chance of severe recurrence of ascites. If surgery is contraindicated, a TIPS must be considered for control of ascites.

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: management and outcome

BACKGROUND

Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites.

METHODS

A retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed.

RESULTS

Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair.

CONCLUSION

Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature

PURPOSE

Umbilical hernias are common in cirrhotics, yet, their management poses several challenges. The objective of this paper was to evaluate the indications, selection criteria, and technical aspects of umbilical hernia repair in patients with cirrhosis and ascites.

METHODS

An extensive review of the literature since 1980 was performed. A survey was also conducted to obtain expert consensus to supplement any available conclusions from the literature.

RESULTS

Nineteen surgeons (45%) responded to the survey. For asymptomatic hernias, all would consider hernia repair in Child's A cirrhosis, but not in more advanced disease, whereas the vast majority would consider the repair of complicated hernias. This seems to reflect the respondents' higher estimates of morbidity and mortality with more advanced liver disease. However, because the recent literature demonstrates much lower morbidity and mortality than in the past, many authors now advocate early elective repair. In addition, uncontrolled ascites appear to be strongly predictive of hernia recurrence (relative risk [RR] 8.5; 95% confidence interval [CI] 2.7-26.9).

CONCLUSIONS

While acknowledging the limitations of this study, it appears that the early repair of umbilical hernias in patients with cirrhosis and ascites is safer than it was in the past and can be considered for selected patients. This may avoid increased morbidity and mortality associated with urgent repair later on. The control of ascites is critical to a successful outcome. Urgent repair of umbilical hernia in cirrhotic patients is indicated when complications develop.

Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair

OBJECTIVE

This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes.

METHODS

Procedures were identified from the Veterans' Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables.

RESULTS

Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1-9.4), diabetes (OR 2.1; 95% CI 1.2-3.8), congestive heart failure (OR 4.0; 95% CI 1.4-11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1-3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3-14.3) was strongly associated with postoperative complications.

CONCLUSION

Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.

Minimally invasive repair of recurrent strangulated umbilical hernia in cirrhotic patient with refractory ascites

To repair a recurrent strangulated umbilical hernia in a cirrhotic patient with refractory ascites, we used a minimally invasive procedure. The laparoscopic repair included a release of the incarcerated small bowel loop and secure of a dual Gortex mesh onto the fascial rim. Our satisfactory long-term results should encourage surgeons to adapt this surgical approach.

Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for patients with medically refractory ascites. Many patients with refractory ascites have umbilical herniation. Incarceration of umbilical hernia has been reported following diuresis, paracentesis, and peritoneovenous shunting. We report 2 cases of umbilical hernia incarceration following resolution of ascites after TIPS.

Abdominal pain in a cirrhotic patient with ascites

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Herniorrhaphy and concomitant peritoneovenous shunting in cirrhotic patients with umbilical hernia

From 1981 to 1987, a total of 40 cirrhotic patients with umbilical hernia were treated either by conventional herniorrhaphy (26) or by herniorrhaphy and concomitant insertion of a peritoneovenous (PV) shunt (14). The aim of concomitant PV shunt insertion was to reduce postoperative complications of herniorrhaphy in those patients with intractable ascites, or in whom difficulty to control postoperative ascites was contemplated. In the group of patients with PV shunt, 8 were class B and 6 were class C according to Child's classification; 7 patients had complicated hernia including 2 patients with skin ulceration, 4 with rupture, and 1 with incarceration. In the group with standard herniorrhaphy, 5 patients were class A and 21 were class B; 13 patients were operated on electively for uncomplicated hernia without ascites, 6 had incarceration, and 7 had skin ulceration. The technical procedure of concomitant PV shunting and hernia repair included: insertion of the valve, surgical repair of the hernia, and insertion of the venous tube. In that order, in-hospital mortality was nil. Postoperative complications included sepsis in 2 patients who had concomitant insertion of a PV shunt, and massive ascitic fluid production in 5 patients treated by conventional herniorrhaphy, resulting in ascitic leak from the surgical wound in 1 case. Recurrence of the hernia was observed in 6 patients treated by conventional herniorrhaphy, and in none who had a patent PV shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Peritoneovenous shunt therapy for leaking ascites in the cirrhotic patient

Review of clinical and operative records of 86 patients at the Minneapolis VA Medical Center and Mount Sinai Hospital undergoing peritoneovenous (PV) shunt for intractable ascites revealed a subgroup of patients (n = 9) who developed leaking ascites prior to shunting. The etiology of leaking ascites was as follows: 1) ruptured umbilical hernia ( UH ) (four patients), 2) repeated paracentesis (three patients), and 3) postoperative incisional ascitic fluid leak (two patients). Initial therapy included local sterile compression dressing, intravenous antibiotics, and management of fluid and electrolytes. All nine patients underwent subsequent closure of the fascial defect and PV shunt to prevent reaccumulation of ascites (simultaneous procedures were performed in five patients). No patient developed postoperative septic complications, organ failure, gastrointestinal bleeding, or encephalopathy. There were no early deaths; however, three late deaths (18 months, 2, and 4 years) were due to variceal bleeding and/or liver failure. Ascites was well controlled in seven patients with PV shunt alone, the other two ultimately responding to medical therapy. We conclude that peritoneal fluid leaks can be treated successfully by repairing the fascial defect and placing a PV shunt. In the absence of infected ascites and clinical peritonitis, PV shunt may be performed simultaneously with closure of UH , thus preventing the reaccumulation of ascites during the immediate postoperative period.

Umbilical hernia repair in patients with cirrhosis. No evidence for increased incidence of variceal bleeding

Umbilical hernias are common in patients with alcoholic cirrhosis. Often elective repair is delayed for fear of precipitating acute variceal bleeding by interruption of portal--systemic venous collaterals. In order to test this hypothesis, the incidence of variceal bleeding following repair of umbilical hernia was determined retrospectively in 22 consecutive patients from our hospital and 74 others from six reports in the literature. Overall the perioperative (less than 3 months postrepair) incidence of variceal bleeding was 11%. This incidence of bleeding was equal to the incidence of bleeding reported in the literature in a group of cirrhotics with varices who did not undergo surgery. In addition, no correlation was seen between patients with a preoperative history of varices or bleeding and those who bled after surgery. Therefore, surgical repair of umbilical hernia can be performed in these patients without additional risk of precipitating variceal bleeding.

Management of spontaneous umbilical hernia disruption in the cirrhotic patient

Umbilical hernia is a common finding in cirrhotic patients with ascites. Spontaneous disruption of the hernia and attendant discharge of ascitic fluid is an unusual and rarely reported complication in these patients and is associated with an overall mortality rate of nearly 30%. During the 5-year period 1977-1982, nine patients with hepatic cirrhosis and ascites were treated for spontaneous rupture of an umbilical hernia. Ascites was attributed to alcoholic cirrhosis in all cases and was present for an average of 21 months prior to rupture. In two cases, failed peritoneovenous shunts resulted in reaccumulation of massive ascites. Initial management included sterile occlusive dressings, fluid repletion, and intravenous antibiotic administration. Hernia repair was performed an average of 4.2 days after rupture. General anesthesia was used in eight cases and local anesthesia in one case. In one instance, the hernia became incarcerated and required urgent repair. Postoperative complications, including wound infection and colonic dilatation, occurred separately in two patients (22%). One patient died of hepatic failure 28 days after operation, for an overall mortality rate of 11%. Surviving patients have been followed for an average of 8 months, and most have done well. Spontaneous rupture of umbilical hernia in patients with ascites occurs uncommonly. Operative management is indicated uniformly and can be conducted safely when the patient's condition has stabilized. The prognosis is favorable for patients with good hepatic reserve.