Herniorrhaphy in Cirrhosis: Operative Approach and Timing

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.