Emergency Umbilical Hernia Repair in Cirrhotic Patients
Yes, you should repair umbilical hernias in cirrhotic patients undergoing emergency surgery, as the risks of not operating (strangulation, rupture, peritonitis) outweigh surgical risks, but this must be performed by an experienced surgeon with hepatology consultation for postoperative ascites management. 1
Emergency Surgery Indications
Emergency repair is mandatory when cirrhotic patients present with:
- Strangulated or incarcerated hernias that cannot be reduced 1, 2
- Ruptured umbilical hernias with or without evisceration 1
- Skin necrosis or ulceration over the hernia sac 3, 4
- Signs of peritonitis from hernia complications 1
The American Association for the Study of Liver Diseases explicitly states that emergent surgery for strangulated or ruptured umbilical hernias must proceed despite the patient having cirrhosis and refractory ascites. 1
Critical Perioperative Management
Surgical expertise is non-negotiable: The operation must be performed by a surgeon experienced in managing cirrhotic patients, with mandatory hepatology consultation for postoperative ascites control. 1 This multidisciplinary approach has reduced operative mortality to as low as 5% for incarcerated or ruptured hernias. 1
Postoperative ascites management is the key determinant of successful outcomes: 1
- Sodium restriction to 2 g/day (90 mmol/day) 1
- Minimize or eliminate IV maintenance fluids 1
- TIPS placement should be considered postoperatively if ascites cannot be controlled medically, as uncontrolled ascites prevents wound healing and increases risk of secondary bacterial peritonitis 1
Mesh Selection in Emergency Settings
The choice of mesh depends on the degree of contamination:
- Clean-contaminated fields (bowel strangulation without gross spillage): Synthetic mesh can be safely used 1, 2
- Contaminated/dirty fields (bowel necrosis with gross spillage): Use biological mesh for defects >3 cm, or primary repair for smaller defects 1, 2
- Avoid absorbable mesh as it leads to inevitable recurrence 2
Mortality and Complication Risks
The evidence clearly demonstrates that emergency surgery in cirrhotic patients carries substantially higher risks than elective repair:
- Emergency repair mortality is 2.67 times higher than elective repair in cirrhotic patients 5
- Cirrhotic patients are 8.5 times more likely to die after hernia repair compared to non-cirrhotic patients 5
- Emergency repairs in cirrhotic patients have a 62% complication rate versus 20% in non-cirrhotic emergency repairs 6
- All major complications (recurrence, wound edema, hepatic coma, variceal hemorrhage) in one series occurred exclusively after emergency surgery 3
However, not operating on complicated hernias carries even greater mortality risk from strangulation, rupture, and sepsis. 2, 4, 5
Critical Pitfalls to Avoid
Rapid ascites removal paradoxically causes incarceration: Large volume paracentesis immediately before or after surgery can precipitate hernia incarceration. 1, 2, 4 Coordinate ascites management carefully with hepatology.
Inadequate postoperative ascites control leads to wound dehiscence and recurrence: The most common cause of surgical failure is uncontrolled ascites postoperatively. 1 Aggressive diuretic therapy and consideration of TIPS are essential.
Delayed surgery increases mortality: Time from symptom onset to surgery is the most important prognostic factor (P<0.005). 2 Once emergency indications are present, proceed expeditiously.