Surgery
Volume 148, Issue 3 , Pages 538-543, September 2010

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: Management and outcome

  • Dana A. Telem, MD

      Affiliations

    • Division of General Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
    • ,
  • Thomas Schiano, MD

      Affiliations

    • Recanati Miller Transplant Institute, Division of Liver Diseases, The Mount Sinai Hospital, New York, NY
    • ,
  • Celia M. Divino, MD

      Affiliations

    • Division of General Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
    • Corresponding Author InformationReprint requests: Celia M. Divino, MD, Chief, Division of General Surgery, Department of Surgery, The Mount Sinai Medical Center, 5 E 98th Street, Box 1259, 15th Floor, New York, NY 10029.

Accepted 11 January 2010. published online 26 March 2010.

Background

Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites.

Methods

A retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed.

Results

Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair.

Conclusion

Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

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PII: S0039-6060(10)00012-7

doi:10.1016/j.surg.2010.01.002

Surgery
Volume 148, Issue 3 , Pages 538-543, September 2010

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