Incarcerated umbilical hernia leading to small bowel ischemia

The impact of compensated and decompensated cirrhosis on the postoperative outcomes of patients undergoing hernia repair: a propensity score-matched analysis of 2011-2017 US hospital database

BACKGROUND AND AIMS

Since there is clinical overlap between populations with cirrhosis and those who require hernia repair (i.e. due to stretching of abdominal walls), we systematically evaluate the effects of cirrhosis on post-hernia repair outcomes.

METHODS

2011-2017 National Inpatient Sample was used to identify patients who underwent hernia repair (included: inguinal, umbilical, and other abdominal hernia repairs). The population was stratified into those with compensated cirrhosis (CC), decompensated cirrhosis (DC), and no cirrhosis; hepatic decompensation was defined as those with portal hypertension, ascites, and varices. The propensity score was used to match the no-cirrhosis controls to CC and DC using the 1:1 nearest neighbor mechanism. Endpoints included mortality, length of stay, costs, and complications.

RESULTS

Postmatch, there were 392/446 CC/DC with equal number controls in those undergoing inguinal hernia repair, 714/1652 CC/DC with equal number controls in those undergoing umbilical hernia repair, and 784/702 CC/DC. In multivariate, for inguinal repair, there was no difference in mortality [CC vs. no-cirrhosis aOR 2.61, 95% confidence interval (CI) 0.50-13.52; DC vs. no-cirrhosis: aOR 1.75, 95% CI 0.84-3.63]. For umbilical repair, there was no difference in mortality for CC vs. no-cirrhosis: aOR 0.94, 95% CI 0.36-2.42); however, DC had higher mortality (aOR 2.86, 95% CI 1.76-4.63) when comparing DC vs. no-cirrhosis. For other abdominal repairs, there was no difference in mortality for CC vs. no-cirrhosis (aOR 1.10, 95% CI 0.54-2.23); however, DC had higher mortality (P < 0.001, aOR 2.58, 95% CI 1.49-4.46) when comparing DC vs. no-cirrhosis.

CONCLUSION

This study demonstrates that the presence of DC affects postoperative survival in patients undergoing umbilical or other abdominal hernia repair surgery.

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.

Umbilical hernia alloplastic dual-mesh treatment in cirrhotic patients

RATIONALE

Abdominal wall hernias represent a pathology with an impressive prevalence among the population of patients with cirrhosis complicated by ascites. The aggressive surgical approach of umbilical hernia for patients with cirrhotic background remains a controversial problem, accompanied by anesthetic and surgical risk. Its indication remains fully justified in case of severe symptoms or life threatening complications: strangulation, incarceration, evisceration.

OBJECTIVE

This article evaluates results obtained by using dual-mesh alloplastic materials for surgical treatment of umbilical hernias affecting cirrhotic patients with incipient liver injury.

METHODS AND RESULTS

Our lot consists of twelve patients with ages between 45 and 65 years, diagnosed with hepatic cirrhosis, without other associated comorbidities. All patients were admitted for strangulated umbilical hernia. Among the analyzed lot, no decease was encountered, the morbidity being limited to two cases of parietal suppuration, solved conservatively, without the mesh removal. There were no ascitic fistulas. No recurrences were registered for a 12 months tracking period.

DISCUSSION

The presence of cirrhosis implies a high anesthetic and surgical risk, the intervention being grafted by a substantial increase of mortality and morbidity in an emergency setting. The development of new alloplastic materials, together with the modern anesthetic techniques, allows superior results for patients with incipient hepatic injury.