What is the recommended surgical management for a cirrhotic patient with fascial dehiscence?

Surgical Management of Fascial Dehiscence in Cirrhotic Patients

For cirrhotic patients with fascial dehiscence, immediate surgical repair using interrupted sutures (rather than continuous sutures) is the recommended technique, combined with aggressive perioperative ascites control through sodium restriction (2000 mg/day) and maximal diuretic therapy (spironolactone up to 400 mg/day plus furosemide up to 160 mg/day). 1, 2, 3

Risk Stratification Before Repair

Before proceeding with surgical repair, assess the following high-risk features that predict mortality:

• Child-Pugh-Turcotte class C (OR 5.52 for mortality) 1
• MELD score ≥20 (OR 2.15 for mortality) 1
• ASA score ≥3 (OR 8.65 for mortality) 1
• Emergency presentation (OR 10.32 for mortality) 4
• Delayed presentation >24 hours after leak onset significantly increases morbidity 1

The British Society of Gastroenterology emphasizes that surgical timing and approach should be determined through multidisciplinary discussion involving hepatologists, surgeons, and anesthetists. 1

Immediate Preoperative Management

Ascites Control

• Perform therapeutic paracentesis to reduce intra-abdominal pressure and minimize ongoing wound leakage, with albumin replacement at 8 g per liter of ascites removed (e.g., 100 mL of 20% albumin per 3 liters removed) 2
• Initiate or optimize diuretics: spironolactone starting at 100 mg/day, titrating up to 400 mg/day, plus furosemide up to 160 mg/day 2
• Strict sodium restriction to 88-90 mmol/day (approximately 2000 mg/day) 2

Infection Prevention

• Obtain ascitic fluid culture immediately if any signs of peritoneal infection, inoculating ascitic fluid into blood culture bottles at bedside 2
• Initiate empiric antibiotics with intravenous cefotaxime 2 g every 8 hours if ascitic fluid PMN count >250 cells/mm³ 2
• Administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 to prevent hepatorenal syndrome if spontaneous bacterial peritonitis is present 2

Surgical Technique

Suture Technique

Use interrupted sutures rather than continuous sutures. A 2021 retrospective cohort study of 110 patients with fascial dehiscence demonstrated that interrupted sutures significantly prevent recurrent dehiscence (OR 0.143,95% CI 0.026-0.784, p = 0.025) compared to continuous sutures. 3 This is particularly critical in cirrhotic patients who already have liver cirrhosis as an independent risk factor for burst abdomen (OR 4.788, p < 0.001). 3

Mesh Considerations

• Avoid synthetic mesh in contaminated fields with necrotic tissue or bowel involvement; use primary repair or biological mesh instead 1
• Consider absorbable intraperitoneal onlay mesh (IPOM) in sterile, controlled ascites cases—while it does not reduce recurrence rates, it significantly reduces the need for additional revision surgeries 3
• Prosthetic mesh increases infection risk in the setting of ascites 4

Monofilament Suture Material

Use monofilament suture materials, which are preferred over braided sutures for fascial closure. 5

Critical Pitfalls to Avoid

• Never perform rapid large-volume paracentesis immediately before surgery, as paradoxical hernia incarceration can occur with sudden pressure changes 1
• Do not leave drains in overnight, as this increases infection risk 2
• Do not withhold paracentesis due to coagulopathy—routine correction of INR or platelet count is not recommended even with significant abnormalities 2
• Never discharge without a concrete postoperative ascites control plan, as inadequate management leads to wound dehiscence recurrence 1

Postoperative Management

Ascites Control

• Strict sodium restriction to 2000 mg/day with minimal IV maintenance fluids 1
• Continue aggressive diuretic therapy (spironolactone up to 400 mg/day plus furosemide up to 160 mg/day) 1
• Monitor serum sodium and creatinine closely; stop diuretics and provide volume expansion if serum sodium falls to 121-125 mmol/L with elevated creatinine (>150 mmol/L) 2

Additional Risk Factor Management

Postoperative delirium is a critical predictor of recurrent dehiscence (OR 13.73,95% CI 1.812-104.023, p = 0.011), requiring aggressive prevention and management strategies. 3

Liver Transplant Evaluation

All patients with decompensated cirrhosis and ascites requiring surgery for fascial dehiscence should be evaluated for liver transplantation, as this is the definitive treatment for ascites and its complications. 2 For transplant candidates, consider whether hernia repair should be deferred until during or after liver transplantation. 4