Is inguinal hernia repair with mesh (surgical material) safe in patients with ascites (fluid accumulation in the abdomen)?

From the Guidelines

Inguinal hernia repair with mesh can be performed safely in patients with ascites, but requires careful consideration of several factors, including medical optimization with diuretics and close monitoring for complications. For patients with mild to moderate ascites, mesh repair is generally considered safe after appropriate medical optimization, which typically includes diuretics like spironolactone (100-400 mg daily) and furosemide (40-160 mg daily) to reduce ascitic fluid, as recommended by the 2021 guidelines on the management of ascites in cirrhosis 1. Severe or refractory ascites should be controlled before surgery, potentially requiring paracentesis, as suggested by the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.

During the procedure, surgeons should use lightweight, macroporous mesh and ensure proper fixation to prevent mesh migration. The use of prosthetic mesh may reduce the recurrence rate but may increase the risk of infections and other complications, as noted in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. Postoperatively, patients require close monitoring for complications including wound infection, seroma formation, and ascitic fluid leakage. The safety of mesh repair in these patients is based on its ability to provide tension-free closure with lower recurrence rates compared to non-mesh techniques. However, the presence of ascites increases infection risk and may compromise wound healing, so perioperative antibiotics (typically cefazolin 1-2g IV) are recommended, as suggested by the 2018 WSES/SIS-E consensus conference recommendations for the management of skin and soft-tissue infections 1.

Some surgeons prefer preperitoneal mesh placement to avoid direct contact between the mesh and ascitic fluid, potentially reducing infection risk. Each case should be evaluated individually, weighing the benefits of hernia repair against the patient's overall condition and ascites severity, considering the guidelines and recommendations from the 2021 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. The most recent and highest quality study, the 2021 practice guidance by the American Association for the Study of Liver Diseases 1, provides the basis for these recommendations, prioritizing morbidity, mortality, and quality of life as the outcome.

Key considerations include:

• Medical optimization with diuretics to reduce ascitic fluid
• Close monitoring for complications, including wound infection and ascitic fluid leakage
• Use of lightweight, macroporous mesh and proper fixation to prevent mesh migration
• Perioperative antibiotics to reduce infection risk
• Individual evaluation of each case, weighing the benefits of hernia repair against the patient's overall condition and ascites severity.

From the Research

Inguinal Hernia Repair with Mesh in Patients with Ascites

• The safety of inguinal hernia repair with mesh in patients with ascites has been evaluated in several studies 2, 3, 4.
• A study published in 2019 found that inguinal hernioplasty can be safely performed in patients with liver cirrhosis and ascites, particularly in those with Child's class A and B 2.
• Another study from 2011 reported that inguinal hernia repair under local anesthesia was safe and effective in patients with cirrhosis and ascites, with no major complications or recurrence observed 3.
• However, a study from 1997 suggested that ascites is a major risk factor for surgery and recommended that surgical repair should not be performed in patients with ascites and poor liver function 4.
• The use of mesh in inguinal hernia repair has been associated with mesh-related visceral complications, which can be rare but serious 5.
• The choice of mesh material and implantation site is crucial to prevent complications, and careful attention must be paid to the hemorrhagic events in patients with ascites and liver cirrhosis 2, 5.

Key Considerations

• Patients with ascites and liver cirrhosis should undergo careful hepatological assessment and be classified according to the Child's class before undergoing inguinal hernia repair with mesh 2.
• The surgical procedure should be performed under local anesthesia, and antibiotic prophylaxis should be administered to prevent infections 2, 3.
• The hospital stay may be longer for patients with ascites and liver cirrhosis, and close monitoring is necessary to prevent postoperative complications 2.
• The use of mesh in inguinal hernia repair should be carefully considered, and alternative approaches may be necessary in patients with refractory ascites and poor liver function 4.