The Current Surgical Managemnt of the Parietal Deffects in Patients with Liver Cirrhosis - Options and Limits. Our Experience and Review of Literature

Abstract

Introducere: Herniile peretelui abdominal au la pacienţii cu ciroză o prevalenţă semnificativ mai mare faţă de pacienţii non cirotici. Modalitatea de abord chirugical şi momentul operator sunt elemente aflate încă în dezbatere. Material şi metodă: Am analizat retrospectiv cazurile de hernii operate la pacienţi cu ciroză hepatică în Clinica de Chirurgie a Spitalului Clinic "Sf. Pantelimon" din Bucureşti în intervalul Ianuarie 2012-Decembrie 2016. Din fişele de observaţie ale pacienţilor am reţinut analizele de laborator (albuminemie, bilirubinemie, timp de protrombină) şi datele clinice (prezenţa ascitei şi encefalopatiei) care au permis încadrarea conform claselor Child, precum şi date referitoare la tipul herniei, caracterul de urgenţă sau electiv al intervenţiei chirurgicale, tehnica operatorie utilizată şi evoluţia postoperatorie. Analiza statistică s-a făcut pe baza testului chi-pătrat. Rezulate: Dintre cel 65 de hernii operate, 32 au fost ombilicale (49,23%), 18 inghinale (27,69%), 11 incizionale (16,92%) şi 4 epigastrice (6,15%). 29 (44,6%) dintre intervenţii au fost efetuate programat, iar 36 (55,4%) au avut caracter de urgenţă. Încadrarea în grupe Child a fost: 24 (36,92%) Child A, 30 (46,15%) Child B, 11 (16,92%) Child C. Morbiditatea postoperatorie a fost de 11 cazuri pentru Child A (45,83%), 17 pentru Child B (56,66%) şi 9 pentru Child C (81,8%). Mortalitatea a fost 1 caz pentru Child A (4,16%),

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

“…In all, 24 of 33 studies3–10,16,18–23,27–35 included cirrhotic patients receiving elective or emergency surgery. Early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve and good general condition,3–7,16,19–21 whereas emergency repair is unequivocally indicated by life-threatening complications, which include rupture, incarceration (not suitable for external reduction), strangulation, and ascites leakage 8–10,16,18,27,44,45…”

“…Early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve and good general condition, [3][4][5][6][7]16,[19][20][21] whereas emergency repair is unequivocally indicated by lifethreatening complications, which include rupture, incarceration (not suitable for external reduction), strangulation, and ascites leakage. [8][9][10]16,18,27,44,45 Spontaneous evisceration of umbilical hernia, also called "flood syndrome," represents a serious incident in cirrhotic patients with massive ascites, 46 and patient management results varied between the operation group and the nonoperative; of note, the mortality rate of patients with conservative treatment was significantly higher than those with surgical management (87% vs. 13%). 6 Therefore, many authors recommend timely surgical interventions for those patients with a spontaneous umbilical rupture.…”

Massive ventral hernia with small bowel obstruction in a cirrhotic patient

“…1 Furthermore, the risk of post-operative morbidity and mortality after emergency hernia repair is significantly higher in cirrhotic patients especially in Child-Pugh C patients which may reach 20%. 6 Our case was an elderly patient with decompensated liver cirrhosis and renal impairment and massive ventral hernia complicated by intestinal obstruction. All these risk factors made the management of this patient very difficult as the definitive repair of the hernia would entail a high risk of mortality and severe post-operative complications such as abdominal compartmental syndrome or liver failure.…”