Hernia Repair in Patients with Cirrhosis

  • Richard Smith


Hernia repair in patients with cirrhosis has historically been associated with significant morbidity and mortality. However, with careful consideration and in well-selected patients, the morbidity and mortality can be acceptable. Some studies have shown worse outcomes for patients undergoing emergent repairs when compared to elective repair. This has prompted some authors to recommend elective repair broadly. However, the differences in outcome between elective repair and emergent repair appear to be more related to the underlying degree of liver dysfunction than acuteness of the indication. Therefore, degree of liver dysfunction, physiologic status, and comorbidities should be weighed carefully. Referral to specialized centers (transplant centers) with a multidisciplinary team who can assist in perioperative care of the patient undergoing hernia repair should also be considered. In patients undergoing surgery, the risk of recurrence and complications can be reduced by maximizing medical treatment of ascites, assessing nutrition, and careful surveillance for infection prior to operation.


Cirrhosis Umbilical hernia Ruptured umbilical hernia Ascites Inguinal hernia Ventral hernia Liver transplantation 


  1. 1.
    Ammar SA. Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia. 2010;14(1):35–8.CrossRefGoogle Scholar
  2. 2.
    Arroyo AG. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88(10):1321–3.CrossRefGoogle Scholar
  3. 3.
    Azoulay DB. Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg. 2001;193(1):46–51.CrossRefGoogle Scholar
  4. 4.
    Baron HC. Umbilical hernia secondary to cirrhosis of the liver. Complications of surgical correction. N Engl J Med. 1960;263:824–8.CrossRefGoogle Scholar
  5. 5.
    Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis. 1997;17(3):219–26.CrossRefGoogle Scholar
  6. 6.
    Belli GD. Laparoscopic incisional and umbilical hernia repair in cirrhotic patients. Surg Laparosc Endosc Percutan Tech. 2006;16(5):330–3.CrossRefGoogle Scholar
  7. 7.
    Carbonell AM. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia. 2005;9(4):353–7.CrossRefGoogle Scholar
  8. 8.
    Carbonell AM. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg. 2013;217(6):991–8.CrossRefGoogle Scholar
  9. 9.
    Chatzizacharias NA. Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol. 2015;21(10):3109–13.CrossRefGoogle Scholar
  10. 10.
    Cho SW, Bhayani N, Newell P, et al. Umbilical hernia repair in patients with signs of portal hypertension: surgical outcome and predictors of mortality. Arch Surg. 2012;147(9):864–9.CrossRefGoogle Scholar
  11. 11.
    Choi SB. Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy. Dig Liver Dis. 2012;43(12):991–5.CrossRefGoogle Scholar
  12. 12.
    Coelho GR. Single-center transfusion rate for 555 consecutive liver transplantations: impact of two eras. Transplant Proc. 2013;45(9):3305–9.CrossRefGoogle Scholar
  13. 13.
    Coelho JC. Umbilical hernia in patients with liver cirrhosis: a surgical challenge. World J Gastrointest Surg. 2016;8(7):476–82.CrossRefGoogle Scholar
  14. 14.
    del Olmo JA, Flor-Lorente B, Flor-Civera B, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg. 2003;27(6):647–52.CrossRefGoogle Scholar
  15. 15.
    Eker HH. A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery. 2011;150(3):542–6.CrossRefGoogle Scholar
  16. 16.
    Fagan SP. Management of complicated umbilical hernias in patients with end-stage liver disease and refractory ascites. Surgery. 2004;135(6):679–82.CrossRefGoogle Scholar
  17. 17.
    Farnsworth NF. Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg. 2004;188(5):580–3.CrossRefGoogle Scholar
  18. 18.
    Forman LM, Lucey MR. Predicting the prognosis of chronic liver disease: an evolution from CHILD to MELD. Hepatology. 2001;33:473–5.CrossRefGoogle Scholar
  19. 19.
    Gines PT. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology. 1988;94(6):1493–502.CrossRefGoogle Scholar
  20. 20.
    Ginsburg BY. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med. 2006;30(2):155–7.CrossRefGoogle Scholar
  21. 21.
    Gray SH. Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. J Gastrointest Surg. 2008;12(4):675–81.CrossRefGoogle Scholar
  22. 22.
    Gurita RE. Umbilical hernia alloplastic dual-mesh treatment in cirrhotic patients. J Med Life. 2013;6(1):99–102.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Hassan AM. Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites. Int J Surg. 2014;12(2):181–5.CrossRefGoogle Scholar
  24. 24.
    Holihan JL. Mesh location in open ventral hernia repair: a systematic review and network meta-analysis. World J Surg. 2016;40(1):89–99.CrossRefGoogle Scholar
  25. 25.
    Horn TW. When a hernia is not a hernia: the evaluation of inguinal hernias in the cirrhotic patient. Am Surg. 2001;67(11):1093–5.PubMedGoogle Scholar
  26. 26.
    Hur YH. Inguinal hernia repair in patients with liver cirrhosis accompanied by ascites. J Korean Surg Soc. 2011;80(6):420–5.CrossRefGoogle Scholar
  27. 27.
    Hurst RD. Management of groin hernias in patients with ascites. Ann Surg. 1992;216(6):696–700.CrossRefGoogle Scholar
  28. 28.
    Juo YS. Laparoscopic versus open ventral hernia repair in patients with chronic liver disease. Surg Endosc. 2017;31(2):769–77.CrossRefGoogle Scholar
  29. 29.
    Kathpalia PB. Indwelling peritoneal catheters in patients with cirrhosis and refractory ascites. Intern Med J. 2015;45(10):1026–31.CrossRefGoogle Scholar
  30. 30.
    Kelly ME. The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg. 2002;68(6):524–8; discussion 528PubMedGoogle Scholar
  31. 31.
    Kirkpatrick S, Schubert T. Umbilical hernia rupture in cirrhotics with ascites. Dig Dis Sci. 1988;33(6):762–5.CrossRefGoogle Scholar
  32. 32.
    Lemmer JH. Management of spontaneous umbilical hernia disruption in the cirrhotic patient. Ann Surg. 1983;198(1):30–4.CrossRefGoogle Scholar
  33. 33.
    Leonetti JP. Umbilical herniorrhaphy in cirrhotic patients. Arch Surg. 1984;119(4):442–5.CrossRefGoogle Scholar
  34. 34.
    Licari LS. The abdominal wall incisional hernia repair in cirrhotic patients. G Chir. 2018;XXXIX(1):20–3.CrossRefGoogle Scholar
  35. 35.
    Maniatis AG. Therapy for spontaneous umbilical hernia rupture. Am J Gastroenterol. 1995;90(2):310–2.PubMedGoogle Scholar
  36. 36.
    Mansour AW. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122(4):730–5. discussion 735Google Scholar
  37. 37.
    Marsman HA. Management in patients with liver cirrhosis and an umbilical hernia. Surgery. 2007;142(3):372–5.CrossRefGoogle Scholar
  38. 38.
    McKay AD. Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia. 2009;13(5):461–8.CrossRefGoogle Scholar
  39. 39.
    Nguyen MT. Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA Surg. 2014;149(5):415–21.CrossRefGoogle Scholar
  40. 40.
    Oh HK. Inguinal hernia repair in patients with cirrhosis is not associated with increased risk of complications and recurrence. World J Surg. 2011;35(6):1229–33; discussion 1234CrossRefGoogle Scholar
  41. 41.
    Patti RA. Inguinal hernioplasty improves the quality of life in patients with cirrhosis. Am J Surg. 2008;196(3):373–8. Am J Surg. 196(3):373–8.CrossRefGoogle Scholar
  42. 42.
    Pei KY. A matched comparison of laparoscopic versus open inguinal hernia repair in patients with liver disease using propensity score matching. Hernia. 2018;22(3):419–26.CrossRefGoogle Scholar
  43. 43.
    Perez-Ayuso RM. Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites. Relationship between the diuretic response and the activity of the renin-aldosterone system. Gastroenterology. 1983;84(5 Pt 1):961–8.CrossRefGoogle Scholar
  44. 44.
    Pescovitz MD. Umbilical hernia repair in patients with cirrhosis. No evidence for increased incidence of variceal bleeding. Ann Surg. 1984;199(3):325–7.CrossRefGoogle Scholar
  45. 45.
    Rossle MO. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med. 2000;342(23):1701–7.CrossRefGoogle Scholar
  46. 46.
    Saleh F, Okrainec A, Cleary SP, Jackson TD. Management of umbilical hernias in patients with ascites: development of a nomogram to predict mortality. Am J Surg. 2015;209(2):302–7.CrossRefGoogle Scholar
  47. 47.
    Sanyal AJ. The North American study for the treatment of refractory ascites. Gastroenterology. 2003;124(3):634–41.CrossRefGoogle Scholar
  48. 48.
    Shlomovitz E, Quan D, Etemad-Rezai R, McAlister VC. Association of recanalization of the left umbilical vein with umbilical hernia in patients with liver disease. Liver Transpl. 2005;11(10):1298–9.CrossRefGoogle Scholar
  49. 49.
    Slakey DP. Umbilical hernia repair in cirrhotic patients: utility of temporary peritoneal dialysis catheter. Am Surg. 2005;71(1):58–61.PubMedGoogle Scholar
  50. 50.
    Stabilini CS. Mesh versus direct suture for the repair of umbilical and epigastric hernias. Ten-year experience. Ann Ital Chir. 2009;80(3):183–7.PubMedGoogle Scholar
  51. 51.
    Stanley MM. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans administration cooperative study on treatment of alcoholic cirrhosis with ascites. N Engl J Med. 1989;321(24):1632–8.CrossRefGoogle Scholar
  52. 52.
    Teh SH. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261–9.CrossRefGoogle Scholar
  53. 53.
    Telem DA. Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: management and outcome. Surgery. 2010;148(3):538–43.CrossRefGoogle Scholar
  54. 54.
    Trotter JF. Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites. Liver Transpl Surg. 1999;5(3):209–10.CrossRefGoogle Scholar
  55. 55.
    Vorst AL. Evolution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg. 2015;7(11):293–305.CrossRefGoogle Scholar
  56. 56.
    Zhu XC. Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: a meta-analysis of outcomes of our current knowledge. Surgeon. 2014;12(2):94–105.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Richard Smith
    • 1
  1. 1.Department of SurgeryUniversity of MissouriColumbiaUSA

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