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Herniorrhaphy in Cirrhosis: Operative Approach and Timing

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Abstract

Hernia management is a common component of surgical practice; however, the treatment of this problem is complex in the setting of cirrhosis and requires a thorough understanding of the pathophysiology of end-stage liver disease to maximize outcomes in those patients that would benefit from operative repair. Multiple aspects of the pathophysiology of cirrhosis can alter outcomes in these patients. Increased intra-abdominal pressure from ascites exacerbates weakening of abdominal fascia, resulting in umbilical hernias or worsening of incisional defects. Malnutrition in these patients can lead to muscle wasting which further undermines abdominal wall architecture (Eher et al. Surgery 150:542–546, 2011). Perioperative management may be complicated by variceal bleeding, exacerbation of hepatic encephalopathy, elevated risk of infectious complications given these patients’ relative immunocompromised state, and fulminant hepatic failure.

Although available literature estimates of ventral hernias in cirrhotic patients occur at a rate of 20%, accurate assessment of risk based on type of hernia (i.e., spontaneous versus incisional), location (i.e., umbilical versus inguinal), and severity of cirrhosis are lacking (Ecker et al. J Surg Res 190:471–477, 2014; Carbonell et al. Hernia 9:353–357, 2005). Given the increased morbidity and mortality among these patients, a multidisciplinary approach that focuses on preoperative optimization, appropriate timing and technique, and reducing postoperative complications is required prior to herniorrhaphy. The following chapter aims to discuss these issues in addition to specific surgical approaches of minimally invasive versus open intervention and the decision to use mesh or primary repair.

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Authors and Affiliations

  1. Division of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Sara P. Myers & Matthew D. Neal

  2. Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Shahid M. Malik

  3. Division of Transplant Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Amit D. Tevar

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  1. Sara P. Myers
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  4. Matthew D. Neal
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Correspondence to Matthew D. Neal .

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Editors and Affiliations

  1. Emory University, Atlanta, GA, USA

    S. Scott Davis, Jr.

  2. Weill Med College At Cornell University, New York, NY, USA

    Gregory Dakin

  3. Stony Brook Surgical Associates, Centereach, NY, USA

    Andrew Bates

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Myers, S.P., Malik, S.M., Tevar, A.D., Neal, M.D. (2019). Herniorrhaphy in Cirrhosis: Operative Approach and Timing. In: Davis, Jr., S., Dakin, G., Bates, A. (eds) The SAGES Manual of Hernia Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-78411-3_47

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