Umbilical hernia management during liver transplantation. Hernia. 2013;17:515-519. [PMID: 23793929 DOI: 10.1007/s10029-013-1131-6]

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat

PURPOSE

Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past.

METHODS

The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia.

RESULTS

Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances.

CONCLUSION

Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.

Umbilical Hernia Repair in Cirrhotic Patients With Ascites: A Systemic Review of Literature

BACKGROUND

Umbilical hernia is a common abdominal complication in cirrhotic patients. The incidence of umbilical hernias can be up to 20% in the presence of ascites. However, there is no consensus regarding the optimal management of umbilical hernias in cirrhotic patients. The purpose of this study is to review the management of umbilical hernias in cirrhotic patients with ascites.

METHODS

A search of the available literature in English since 1980 was performed using PubMed, the Cochrane Library, and a search of relevant journals and reference lists. The search terms included "umbilical hernia," "ascites," "cirrhosis," and any derivatives of these terms, and the literature search identified all the relevant publications.

RESULTS

Thirty-three relevant articles published in the language of English were identified. Fourteen studies involved the management of refractory ascites in cirrhotic patients. Twenty-four studies included cirrhotic patients receiving elective or emergency surgery. Because of much lower morbidity and mortality in elective surgery than in emergency surgery, many authors advocated early elective repair of uncomplicated umbilical hernias in cirrhotic patients. Of these, 2 studies described laparoscopic umbilical hernioplasty, with a significant lower morbidity and hernia recurrence than open repair. Fifteen studies described the use of prosthetic mesh umbilical hernia repair in cirrhotic patients, which was associated with minimal wound-related morbidity and markedly lower recurrences.

CONCLUSIONS

Our results indicate that early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve or when the expected time for liver transplantation is >3 months. Umbilical hernias are supposed to be corrected in the process of liver transplantation, provided that patients could have a better prospect to be transplanted within 3 months. Control of ascites is a crucial part to successful outcomes of umbilical hernia repair. Large volume paracentesis, concomitant peritoneovenous shunting with herniorrhaphy and transjugular intrahepatic portosystemic shunting can be applied to control refractory ascites. Emergency repair of umbilical hernias is indicated in cirrhotic patients with ascites when complications develop.

Flood Syndrome: A Rare and Fatal Complication of Umbilical Hernia in Liver Cirrhosis

Flood syndrome, first reported in 1961 by Frank B Flood, refers to spontaneous umbilical hernia rupture followed by a sudden rush of ascitic fluid. It is a rare sequela in the setting of refractory ascites and liver cirrhosis. Clues to impending rupture include color changes, ulceration, or necrosis over the umbilical hernia that warrants urgent surgical intervention. In this report, we present a unique case of Flood syndrome in a patient with decompensated cirrhosis and umbilical hernia. The patient underwent urgent umbilical herniorrhaphy without mesh; even though adequate postoperative management of ascites was performed, the patient still developed other comorbidities.

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.

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.

Umbilical hernia in patients with liver cirrhosis: A surgical challenge

Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

Managing complications in cirrhotic patients

Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.