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The incidence of abdominal wall hernias in the general population is considered to be around 14%. It increases to 20% in cirrhotic patients and to 40% in cases of major ascites. Considering umbilical hernia, its incidence in the general population is 2% and it increases to 20% in cirrhotic patients with ascites.
Several factors such as malnutrition, abdominal wall muscle weakness due to hypoalbuminemia and recanalization and increased intraabdominal pressure due to the presence of ascites are major risk factors for the development of abdominal hernias in cirrhotic patients.
Ascites may promote hernia incarceration of intestine or omentum into the hernia ring. Intraabdominal hypertension caused by ascites may cause pressure necrosis and perforation of the skin followed by evisceration, ascites drainage and peritonitis.
Traditionally, abdominal wall hernia repair in these patients has resulted in high rates of morbidity and mortality, prompting the acceptance of a watch-and-wait policy that, as is nowadays known, is associated with high morbidity and mortality. Non-operative management of complicated umbilical hernias in cirrhotic patients with antibiotics and dressing changes is reported to be associated with a mortality rate ranging between 60% and 88%.
Abdominal wall hernia in cirrhotic patients is associated with great discomfort, a decrease in quality of life, and risk of life threatening complications such as incarceration, evisceration, skin rupture with ascites drainage and peritonitis.
It is now accepted that, after optimization of the cirrhotic patient, elective hernia repair should follow. Indications and the optimal timing remain controversial. Optimization may include ascites treatment and nutritional support. Effective treatment of ascites is essential to reduce the postoperative complications in cirrhotic patients. Ascitis control will reduce complications such as wound infection, evisceration, ascites drainage from the wound and peritonitis.
Medical treatment of ascites with sodium restriction, diuretics and paracentesis is the first step in the treatment. If this fails, ascites drainage or shunting is indicated (intermittent paracentesis, temporary peritoneal dialysis catheter of transjugular intrahepatic portosystemic shunt - TIPS). Ascites drainage should be gradual because rapid preoperative drainage may cause strangulation of the hernia.
In patients candidate to liver transplantation abdominal wall hernia should be repaired during transplant operation. If more than 6 months are expected until liver transplantation, hernia repair should be considered after ascites control. If liver transplantation is expected before 3 to 6 months, hernia repair should be performed during transplantation. Hernia repair may be performed from inside the abdomen using the same transplantation incision or through a para-umbilical incision. A small retrospective study by Goede et al. concluded that same incision repair was associated with higher risk of recurrence than separate incision repair (40% vs 6%).
Elective abdominal wall repair with a mesh in cirrhotic patients with ascites is simple, safe, effective, and reduces hernia recurrence (14.2% vs 2.7%). There are still concerns about the safety of mesh repair due to the risk of wound complications such as ascites leakage through the wound, which increases the risk of wound and mesh infection. Several techniques have been described: onlay, inlay, sublay or underlay. For open surgery, the best abdominal wall layer to place the mesh is controversial although the sublay approach is associated with a lower risk for postoperative wound complications. For laparoscopic repair, the mesh is routinely fixed in the underlay position.
The laparoscopic approach has been demonstrated to have the following advantages over the open approach in cirrhotic patients:
Technical tips in laparoscopic repair of abdominal wall defects in the cirrhotic patient are: oblique insertion of trocars into the abdominal wall to avoid ascitic fistula, Veress needle and trocar insertion should be carefully used to avoid damage to the enlarged spleen and reduction of the incarcerated contents should be meticulously performed to avoid damage to the umbilical varices.
Hernia recurrence rate ranges from 0% to 40%. A recent meta-analysis compares recurrence in patients without ascites control (45%) and patients with ascites control (4%). Mesh repair is associated with lower recurrence (2.7%) compared to non-mesh repair (14.2%). However, it seems that wound complications such as seroma, hematoma, wound and mesh infection, are higher in the mesh-repair group.
Emergencies such as incarceration, perforation, strangulation and skin ulceration, are associated with a higher risk for postoperative complications (OR 6.42, 95% IC 1.76 - 40.53, p = 0.023), including death (OR 10.32, 95% IC 3.66 - 47.82, p = 0.021), compared to elective surgery.
Conclusions.
The incidence of abdominal wall hernia increases in cirrhotic patients, especially in those with ascites. Elective repair should be considered in all patients due to the high risk of complications following watch-and-wait policy and emergency repair. In patients in which liver transplantation is expected to occur between 3 to 6 months, hernia repair should be performed during liver transplantation. Laparoscopic hernia repair is associated with several advantages over the open approach. Recurrence is reduced in the mesh repair group, although there is some concern regarding a higher risk of wound complications.