What is the treatment approach for an umbilical hernia with ascites?

Management of Umbilical Hernia with Ascites

The primary treatment strategy for umbilical hernia with ascites is aggressive medical control of ascites with sodium restriction (2000 mg/day) and diuretics (spironolactone up to 400 mg/day plus furosemide up to 160 mg/day), combined with a multidisciplinary decision regarding timing of surgical repair based on liver transplant candidacy, MELD score, and presence of complications. 1

Initial Medical Management: Control Ascites First

The cornerstone of treatment is optimizing ascites control before considering any surgical intervention, as uncontrolled ascites dramatically increases surgical morbidity and mortality. 1

Medical therapy consists of:

• Sodium restriction to 88-90 mmol/day (approximately 2000 mg/day) 1
• Spironolactone starting at 100 mg/day, titrating up to 400 mg/day 1
• Furosemide added if spironolactone alone fails, up to 160 mg/day 1
• Large volume paracentesis (LVP) for tense ascites, with albumin infusion (8 g/L removed if >5L) 1

Conservative hernia management during medical optimization:

• Abdominal binders to minimize hernia progression 1, 2
• Nutritional optimization to prevent further weakening of abdominal wall 1
• Avoid activities that increase intra-abdominal pressure 2

Critical Decision Point: Liver Transplant Candidacy

If Transplant Candidate (Near Future)

Defer hernia repair until during or after liver transplantation. 1 This is the most important decision point, as it avoids unnecessary surgery in patients who will undergo transplantation. 1

• Continue medical management of ascites with binders for hernia support 1
• Proceed to transplant evaluation urgently 1
• Repair hernia at time of transplant surgery 1

If NOT Transplant Candidate or Low MELD Score

Consider elective herniorrhaphy after careful risk-benefit assessment, but only after ascites is controlled. 1

Timing considerations:

• Elective repair is strongly preferred over emergency repair (emergency surgery has OR 10.32 for mortality) 1
• Ascites must be clinically controlled before elective surgery 1
• Laparoscopic approaches are preferred when feasible 1

When Ascites is Refractory to Medical Management

If ascites cannot be controlled with maximum medical therapy (refractory ascites), additional interventions are needed before hernia repair:

TIPS (Transjugular Intrahepatic Portosystemic Shunt):

• Should be considered for refractory ascites to enable hernia repair 1, 3
• Allows better ascites control perioperatively 1, 3
• Reduces risk of wound dehiscence and hernia recurrence 1

Exercise caution with TIPS if:

• Age >70 years 1
• Bilirubin >50 μmol/L 1
• Platelet count <75×10⁹/L 1
• MELD score ≥18 1
• Current hepatic encephalopathy 1

Emergency Situations: Immediate Surgical Intervention Required

Operate emergently if any of these complications develop:

• Incarceration (inability to reduce hernia) 1, 2
• Strangulation (compromised blood supply) 1, 2
• Skin ulceration or necrosis over the hernia 1, 2
• Rupture with ascitic fluid leak 1, 4
• Evisceration 1

Critical pitfall: Rapid removal of ascitic fluid (e.g., large volume paracentesis) can paradoxically cause incarceration. 1 Monitor closely after LVP.

Emergency surgery mortality considerations:

• Non-operative management of complicated hernias has 60-88% mortality 1
• Emergency surgery has significantly higher mortality than elective repair 1
• Multidisciplinary approach with experienced hepatology and surgical teams can reduce operative mortality to as low as 5% for incarcerated/ruptured hernias 1

Surgical Technique When Repair is Indicated

For elective repair:

• Laparoscopic approach preferred (avoids skin incision and ascitic leak) 1, 5
• Prosthetic mesh may be used if ascites is sterile and controlled 1, 5
• Mesh reduces recurrence but increases infection risk 1

For emergency repair with contamination:

• Primary suture repair preferred over mesh if bowel resection or contaminated field 2
• Excise necrotic skin tissue 5

Postoperative management is critical:

• Sodium restriction to 2000 mg/day (90 mmol/day) 1
• Minimize IV maintenance fluids 1
• Continue diuretics to prevent ascites reaccumulation 1
• Optimize nutrition 1

Risk Stratification for Surgical Mortality

High-risk features associated with increased mortality: 1

• Emergency surgery (OR 10.32)
• Child-Pugh-Turcotte class C (OR 5.52)
• ASA score ≥3 (OR 8.65)
• MELD score ≥20 (OR 2.15)

These patients require particularly careful consideration and optimization before any elective surgery.

Algorithm Summary

1. Diagnose umbilical hernia with ascites → Start aggressive medical management of ascites
2. Assess for complications → If present (incarceration, strangulation, rupture, skin necrosis) → Emergency surgery
3. If no complications → Evaluate liver transplant candidacy
   • Transplant candidate → Defer repair until transplant
   • Not transplant candidate or low MELD → Optimize ascites control
4. If ascites controlled medically → Consider elective repair with multidisciplinary team
5. If refractory ascites → Consider TIPS before surgery (if appropriate candidate)
6. Surgical approach → Laparoscopic preferred, mesh if sterile field
7. Postoperative → Strict sodium restriction, diuretics, nutritional optimization