Umbilical hernias and cirrhose

Abstract

Umbilical hernia (UH) is the most frequent abdominal wall complication of ascites in cirrhotic patients. Treatment to control ascites, which mainly consists of repeated paracentesis or transjugular intrahepatic portosystemic shunt (TIPS), is mandatory; otherwise the risk of hernia recurrence is very high. Nowadays, surgical portosystemic shunts are rarely performed. Classically, hernia repair was offered only to patients with symptomatic UH, but presently, even if the hernia is minimally symptomatic, there is tendency to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (rupture and strangulation). If liver transplantation is indicated, treatment of UH can be performed simultaneously, unless the hernia is highly symptomatic or complicated or if the waiting time on the transplantation list is long. During repair, necrotic skin tissue should be excised; the use of prosthetic material (if the defect is large) is possible with a low risk of infection as long as ascites is sterile. The advantage of laparoscopic repair of large UH is to avoid any skin incision (precluding ascitic fluid leak) and avoid exposing prosthetic mesh to necrotic infected tissue. If the defect is small, UH repair can be performed under local anesthesia.

Current options in umbilical hernia repair in adult patients

“…Traditionally, umbilical hernia in patients with cirrhosis and with un- controlled ascites was associated with significant mortality and morbidity and a significantly greater incidence of recurrence (47). However, recent reports for elective repair are more promising, and there is tendency to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (48,49). Early elective repair of umbilical hernias in patients with cirrhosis is advocated considering the hepatic reserve and patient's condition (50).…”

Patient Optimization is the Key in Surgical Repair of Ruptured Umblical Hernia in Cirrhotic Patients and Tense Ascitis

“…Incidence of hernia in cirrhotics with ascites is 20% [5,16]. Literature is scarce about spontaneous rupture of hernia [10].…”

Cirrhosis-related musculoskeletal disease: radiological review

“…60 ABDOMINAL WALL HERNIA Abdominal wall hernias, especially umbilical hernias, are common in patients with liver cirrhosis and ascites, with an overall incidence of approximately 20% (up to 40% in cases of major ascites). [62][63][64][65] While the most common predisposing factor is increased abdominal pressure secondary to the presence of tense ascites (Figure 16), other contributory factors include weakening of the abdominal wall fascia and muscles owing to malnutrition and progressive muscle wasting. Another factor implicated is the dilatation and recanalization of umbilical veins, which leads to abdominal wall weakening and herniation at umbilicus.…”

“…Another factor implicated is the dilatation and recanalization of umbilical veins, which leads to abdominal wall weakening and herniation at umbilicus. 62,63 While the majority of patients remain asymptomatic, nevertheless, these patients are at a higher risk of complications such as incarceration, bowel strangulation, spontaneous rupture, ulceration, fistulae etc. 62,63 One has to be mindful that rapid removal of the ascitic fluid during paracentesis can predispose these patients to incarceration.…”

“…Ideally, these patients should undergo hernia repair either during or after successful liver transplantation. 63,65 BODY FAT OEDEMA Fat oedema in patients with liver cirrhosis can be a result of multiple factors. The most important pathogenic mechanism is portal hypertension causing increased hydrostatic pressure within the mesenteric veins leading to egress of fluid into the mesentery.…”