umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of...

REVIEW

Umbilical hernia repair in the presence of cirrhosis and ascites:results of a survey and review of the literature

A. McKay Æ E. Dixon Æ O. Bathe Æ F. Sutherland

Received: 24 April 2009 / Accepted: 10 July 2009 / Published online: 4 August 2009

� Springer-Verlag 2009

Abstract

Purpose Umbilical hernias are common in cirrhotics, yet,

their management poses several challenges. The objective

of this paper was to evaluate the indications, selection

criteria, and technical aspects of umbilical hernia repair in

patients with cirrhosis and ascites.

Methods An extensive review of the literature since 1980

was performed. A survey was also conducted to obtain

expert consensus to supplement any available conclusions

from the literature.

Results Nineteen surgeons (45%) responded to the sur-

vey. For asymptomatic hernias, all would consider hernia

repair in Child’s A cirrhosis, but not in more advanced

disease, whereas the vast majority would consider the

repair of complicated hernias. This seems to reflect the

respondents’ higher estimates of morbidity and mortality

with more advanced liver disease. However, because the

recent literature demonstrates much lower morbidity and

mortality than in the past, many authors now advocate

early elective repair. In addition, uncontrolled ascites

appear to be strongly predictive of hernia recurrence (rela-

tive risk [RR] 8.5; 95% confidence interval [CI] 2.7–26.9).

Conclusions While acknowledging the limitations of this

study, it appears that the early repair of umbilical hernias in

patients with cirrhosis and ascites is safer than it was in the

past and can be considered for selected patients. This may

avoid increased morbidity and mortality associated with

urgent repair later on. The control of ascites is critical to a

successful outcome. Urgent repair of umbilical hernia in

cirrhotic patients is indicated when complications develop.

Keywords Umbilical hernia � Liver cirrhosis �Surgery � Survey � Review

Abbreviations

HPB Hepato-pancreatico-biliary

TIPS Transjugular intrahepatic portosystemic shunt

PVS Peritoneovenous shunt

PV Peritoneovenous

Introduction

Umbilical hernias are common among patients with cir-

rhosis and uncontrolled ascites [1, 2]. Complications of

these hernias can be serious, and mortality rates as high as

30% have been reported [3]. Skin ulceration and sub-

sequent rupture of the hernia sac and leakage is common,

which can result in bacterial peritonitis and serious mor-

bidity [2]. Historically, the very high peri-operative mor-

bidity and mortality in this patient population have

precluded repair in the elective setting [4, 5]. More recent

publications have reported improved outcomes, however.

This has prompted some to consider early repair [6] to

avoid the need to operate in an emergency situation, where

morbidity and mortality remain high [7].

Electronic supplementary material The online version of thisarticle (doi:10.1007/s10029-009-0535-9) contains supplementarymaterial, which is available to authorized users.

A. McKay (&)

Department of Surgery, Health Sciences Centre,

University of Manitoba, GF-441, 820 Sherbrook St.,

Winnipeg, MB R3A 1R9, Canada

e-mail: [email protected]

E. Dixon � O. Bathe � F. Sutherland

Department of Surgery, University of Calgary,

Calgary, AB, Canada

123

Hernia (2009) 13:461–468

DOI 10.1007/s10029-009-0535-9

http://dx.doi.org/10.1007/s10029-009-0535-9

The control of ascites in these patients presents a further

dilemma. Uncontrolled ascites can negatively influence

recurrence rates and morbidity rates [8]. In addition to the

medical treatment of ascites, concomitant peritoneovenous

shunting at the time of herniorrhaphy [2, 9] and the use of

temporary peritoneal dialysis catheters [10] have been

shown to reduce recurrence rates by controlling ascites.

Nonetheless, successful treatment of this problem

remains a difficult challenge. Patient selection, indications

for repair, and the technical aspects of repair are still

controversial. There are no high-quality randomized stu-

dies (Level I evidence [11]) to guide decision-making. The

purpose of this study was to extensively review the recent

literature in an attempt to solve some of these controversies

and to provide treatment recommendations. Because the

current literature is limited, a survey was also conducted to

try to obtain consensus opinion that might supplement any

conclusions drawn from the available literature. The

objective of this paper was to evaluate the indications,

selection criteria, and technical aspects of umbilical hernia

repair in patients with cirrhosis and ascites.

Methods

Design

The study consisted of a survey administered to experts in

the field of hepatobiliary surgery across Canada, identified

through the mailing list of the Canadian Hepato-Pancreato-

Biliary Society (CHPBS). In addition, a comprehensive

review of the literature was performed.

Survey

A 13-question survey was administered by email to 40

experts in the field of hepatobiliary and transplant surgery

across Canada. The survey was created and administered

using a widely available internet tool (http://www.

surveymonkey.com). See the supplementary material for

the survey questions. For surgeons who did not reply to the

initial email, a second reminder was sent after 2 weeks.

Literature search

A literature search using PubMed (MEDLINE) and EM-

BASE databases was performed using the search terms

‘ascites’ and ‘umbilical hernia.’ Articles were limited to

those published in English since 1980 and only publica-

tions reporting the surgical repair of umbilical hernias in

adult patients were included. The papers were required to

include a follow-up period beyond the initial hospital dis-

charge so that recurrence rates could be evaluated. Articles

considered for inclusion in the review were clinical trials,

case series, and case reports. Review articles and letters to

the editor were excluded. In addition to the database

search, the references of the identified papers were sear-

ched for other eligible publications that were not previ-

ously identified.

Studies that reported a control group of patients who had

hernia repairs without simultaneous procedures to control

ascites were pooled to provide an estimate of the relative

risk (RR) reduction achieved by controlling ascites at the

time of herniorrhaphy. Both an unadjusted pooled RR ratio

and a meta-analysis using Mantel–Haenszel methods

(Stata� 8.0 for Windows, Stata Corporation, 2003) were

calculated.

Results

Survey

The survey was sent electronically to 40 surgeons across

Canada. Nineteen replied, for a completion rate of 45%.

However, only 16 answered every question. The first

question asked whether the respondents would consider

surgically repairing an umbilical hernia in a patient with

cirrhosis and ascites. All respondents indicated that they

would, with 16% responding ‘Yes,’ and 84% responding ‘It

depends’ on the circumstances. In order to explore which

factors might influence the selection criteria for surgical

repair, the respondents were asked to estimate the inci-

dence of morbidity and mortality following hernia repair

among patients with different Child–Pugh classifications

(see Table 1). The majority of respondents thought that the

severity of the symptoms related to the hernia, the severity

of cirrhosis, and the presence of ascites were important in

decision-making (Table 2). This is reflected in Table 3,

which shows that all respondents would consider the repair

of an asymptomatic hernia in a patient with Child’s A

cirrhosis, but not in Child’s B or C cirrhosis. The majority

would, however, perform repair for complications regard-

less of the severity of cirrhosis.

Table 1 Estimates of morbidity and mortality following the repair of

umbilical hernia in cirrhotics

Estimatea Child–Pugh classification

A B C

Morbidity 13.9 (2–30) 27.5 (10–60) 53.1 (10–100)

Mortality 3.8 (0–10) 13.2 (3–40) 28.9 (15–70)

a Values represent the means of the survey respondents’ estimates in

percentages, with the ranges in brackets

462 Hernia (2009) 13:461–468

123

http://www.surveymonkey.com

http://www.surveymonkey.com

Because uncontrolled ascites negatively affects outcome

[8], most (11 respondents, or 69%) would consider a con-

comitant procedure to surgically control the ascites in the

postoperative period. Among these 11 respondents, their

willingness to offer a procedure to control ascites increased

with the severity of the ascites (Table 4). Most of these

respondents (nine respondents, or 82%) would consider a

peritoneal drain or dialysis catheter to temporarily control

the ascites. Alternatives included a peritoneovenous shunt

(PVS, one respondent), serial percutaneous drainage (one

respondent), and transjugular intrahepatic portosystemic

shunt (TIPS) procedures (one respondent). Regarding sur-

gical technique, the respondents were split evenly between

those who would use prosthetic mesh and those who would

not. As shown in Table 5, the willingness to use mesh

decreased for more advanced liver disease.

Literature review

A total of 56 papers were identified during the literature

search. Of these papers, 16 were included in the literature

review. None of these papers reported prospective clinical

trials. Three papers were observational cohort studies and

the rest were retrospective cases series reporting between

one and nine subjects. Papers were excluded because they

did not report the surgical repair of umbilical hernias (29

papers), they were based on pediatric patients (four

papers), they were review articles (three papers), or they

were letters to the editor (four papers). The search strategy

is shown in Fig. 1.

Discussion

Indications and timing of repair

The indications for umbilical herniorrhaphy in cirrhotic

patients remain controversial, and, unfortunately, there are

no high-quality prospective studies to address this question.

Different authors have taken different viewpoints based

largely on retrospective case series. One outstanding issue

is whether to repair hernias when they are asymptomatic or

Table 2 Importance of factors in the decision to repair hernias

Very important Important Minor importance Not important at all

Control of ascites (%) 75 (12) 19 (3) 6 (1) 0 (0)

Child’s classification (%) 75 (12) 25 (4) 0 (0) 0 (0)

Albumin level (%) 19 (3) 44 (7) 38 (6) 0 (0)

Severity of symptoms (%) 75 (12) 19 (3) 6 (1) 0 (0)

Total respondents 16

Table 3 Indications for the repair of umbilical hernias

Child’s Aa Child’s Ba Child’s Ca Respondent total

Asymptomatic hernia (%) 100 (8) 0 (0) 0 (0) 8

Incarcerated hernia (%) 79 (11) 86 (12) 86 (12) 14

Ruptured hernia (leaking ascites) (%) 88 (14) 88 (14) 94 (15) 16

Impending rupture (e.g., skin breakdown) (%) 88 (14) 88 (14) 69 (11) 16


a Values represent the percentage of respondents, with the number of respondents in brackets

Table 4 Percentage of respondents who would offer concomitant procedure to control ascites surgically


Asymptomatic hernia (%) 20 (1) 60 (3) 80 (4) 5






Hernia (2009) 13:461–468 463

123

to wait until complications arise. Traditionally, hernia

repair in the presence of advanced cirrhosis and ascites has

resulted in high rates of morbidity and mortality, prompting

many to avoid elective repair and to operate only when

complications develop [2]. In 1960, Baron reported a

mortality rate of 31% in 16 patients with cirrhosis who

underwent umbilical hernia repair [4]. O’Hara et al.

reported a morbidity rate of 22% and a mortality of 16%,

leading them to suggest that surgical repair should be

delayed in uncomplicated hernias [5].

While in the past it was commonly advised against the

repair of uncomplicated hernias, there has been little dis-

agreement with operative repair when complications have

arisen [5, 7, 8]. These complications included incarceration

or strangulation, spontaneous rupture, or impending rupture

(skin necrosis and ulceration over the hernia). The risk of

treating these complications conservatively heavily out-

weighs the risk of surgical repair. Non-operative manage-

ment of ruptured hernias with antibiotics and dressing

changes may result in mortality rates in the range 60–88%

[3, 7]. Thus, complicated umbilical hernias in cirrhotics

should be repaired urgently.

Although many have advised against elective repair,

there is a considerable lack of evidence regarding how

severe the liver dysfunction must be in order to preclude

operative repair. In other words, there does not appear to be

any reliable, commonly accepted methods to determine

whether the cirrhosis is too severe to allow for elective

repair or whether it is mild enough that the risk of major

complications is low enough to justify the repair. Serum

albumin levels may be prognostic. Fisher and Calkins

report that, among 21 patients with cirrhosis undergoing

herniorrhaphy, there were no mortalities when the serum

albumin level was above 24 g/L [12]. It has also been

suggested that the ability to control ascites may be a

prognostic factor. When ascites persisted despite vigorous

medical therapy, the mortality and morbidity were 5 and

30%, respectively (compared to 0 and 15%, respectively,

when it was possible to control the ascites) [8].

More recent reports have demonstrated much lower

mortality and morbidity rates (see Table 6). Lately, sur-

geons have been more willing to undertake elective

umbilical hernia repair in cirrhotic patients. It has been

argued that the improved complication rates associated

with modern surgical techniques and peri-operative care

justifies the consideration of an early repair before com-

plications do arise. Kirkpatrick and Schubert reported

improved outcomes and lower mortality in patients treated

after 1975 compared to prior to 1975 [7]. Waiting until

complications arise may be associated with higher mor-

bidity and mortality. A review by Maniatis and Hunt of

papers published between 1956 and 1990 found a mortality

rate of only 2% in the non-urgent setting, while the mor-

tality rate was 14% with repair due to complications carried

out as an emergency [6]. All but three series identified in

the literature review since 1980 have reported no mortality,

even though these series included significant numbers of

patients with complicated hernias. Lemmer et al. [3]

reported one mortality out of eight patients who underwent

urgent operations for ruptured hernias. Leonetti et al. [13]

reported two deaths out of 39 cirrhotics undergoing

umbilical herniorrhaphy, but the breakdown between

urgent and elective cases was not reported. Similarly,

Pescovitz reported one operative death in a series of 22

Table 5 Percentage of respondents who would use prosthetic mesh in the repairs


Elective repair (%) 100 (6) 67 (4) 50 (3) 6




Total respondents 6


Fig. 1 Search strategy

464 Hernia (2009) 13:461–468

123

cirrhotic patients, but it is not stated whether this was in an

urgent or an elective situation [18]. Therefore, it appears

that mortality rates have fallen dramatically and both

urgent and elective herniorrhaphy appears to be relatively

safe. Of the 183 reported patients identified in this review,

there were only four operative deaths (2.7%).

While these recent figures are very impressive, it must

be kept in mind that these are generally small retrospective

series. These patients who underwent elective repair of

uncomplicated umbilical hernias were likely to be highly

selected. In addition, it is likely that a publication bias

exists and these more recent publications may not be

entirely reflective of the general experiences in clinical

practice.

The data from a series reported by Belghiti et al. [8]

showed that, as the severity of the cirrhosis increased,

patients were less likely to be selected for elective herni-

orrhaphy for uncomplicated hernias. Among patients with

class A, B, and C cirrhosis, the frequencies for which

hernia repairs that were done on an elective basis rather

than for complications of the hernia were 80, 52, and 17%,

respectively. The results of the present survey reflect this

attitude. Estimates of morbidity and mortality associated

with hernia repair were low for Child’s A cirrhotics, but

rose dramatically as the severity of the liver disease

increased (Table 1). Furthermore, 100% of the respondents

would electively repair an umbilical hernia in the presence

of Child’s A cirrhosis, but not in B or C cirrhosis. In

contrast, the vast majority would operate for complicated

hernias regardless of the Child’s status.

In summary, it seems that the elective repair of

uncomplicated umbilical hernias is safe in selected patients

and that past reports of prohibitive morbidity and mortality

are too high by current results. The risks of delayed repair

on an urgent basis when complications arise may be higher

than the risks of early prophylactic repair. Unfortunately,

proper selection criteria are lacking and surgeons must use

clinical judgement, and while improved mortality and

morbidity rates have prompted many to propose early

repair, it appears that, with increasing Child’s classifica-

tion, many are still reluctant to do this.

Strategies to control ascites

A frequent theme in the literature is the importance of

controlling the ascites, as it relates to a successful outcome.

Since ascites is commonly cited as a causative factor in the

development of these umbilical hernias, it follows that the

presence of uncontrolled ascites postoperatively might lead

to more frequent recurrences. The literature review identi-

fied three retrospective cohort studies comparing a group of

Table 6 Morbidity and mortality reported in the literature since 1980

Author Year Total

Patients Mortality Morbidity

Lemmer et al. [3] 1983 9 1 2

Leonetti et al. [13] 1984 39 2 5

Pescovitz [18] 1984 22 1 18

Bunt and Mohr [19] 1985 2 0 0

O’Connor et al. [9] 1984 9 0 2

Runyon and Juler [14] 1985 22 0 4

Belghiti et al. [8] 1990 40 0 5

MacLellan et al. [20] 1990 1 0 0

Maniatis and Hunt [6] 1995 1 0 0

Ozden et al. [21] 1998 9 0 3

de la Pena et al. [16] 2000 15 0 0

Granese et al. [22] 2002 1 0 0

Sarit et al. [23] 2003 1 0 0

Fagan et al. [24] 2004 3 0 0

Sherman and Lee [25] 2004 1 0 0

Slakey et al. [10] 2005 8 0 0

Total 135 4 (2.7%) 39 (21%)

Table 7 Recurrence rates according to success in controlling ascites

Author Year n Mean

age

Follow-up

(months)

Intervention

for ascites

Intervention Recurrent

ascites

n Recurrent

hernia (n)

Belghiti et al. [8] 1990 40 54 [6 Yes PVS Yes 4 4

No 10 0

No – Yes 10 6

No 16 1

Leonetti et al. [13] 1984 39 – 8–96 Noa – Yes 24 4

Yes PVS No 15 0

Runyon and Juler [14] 1985 17b 50.3 24 (mean) Yes Medical Yes 11 8

No 6 1

a This group contains patients with no intervention for ascites and patients with failed interventions for ascites (i.e. non-functioning PVS)b This series contained 22 patients, but only 17 had full follow-up data available

Hernia (2009) 13:461–468 465

123

cirrhotic patients who underwent repair of umbilical hernia

with simultaneous interventions to the control ascites to a

group who underwent herniorrhaphy alone (see Table 7).

All repairs were primary repairs without prosthetic mesh.

Belghiti et al. [8] compared of 26 cirrhotics who had

umbilical herniorrhaphy alone (half of whom had ascites

preoperatively) to 14 cirrhotics who had umbilical hernia

repair and concomitant PVS insertion. The follow-up

duration was at least 6 months in all cases. Of the 14 cir-

rhotics who underwent concomitant PVS insertion, two

required shunt removal due to postoperative complications

and two shunts became occluded. In each of these four

patients, ascites and the hernia recurred. In all, there were

14 patients who developed recurrent ascites, and ten of

these (71%) developed a recurrent umbilical hernia. In

contrast, there was only one recurrence in the 26 patients

(4%) who did not develop recurrent ascites.

Leonetti et al. [13] found a higher recurrence rate after

umbilical hernia repair in cirrhotic patients with uncon-

trolled ascites than in cirrhotic patients with controlled

ascites or in patients without cirrhosis. Between 1972 and

1982, they identified 15 cirrhotics with functioning perito-

neovenous (PV) shunts, 24 cirrhotics without a functioning

shunt (three had occluded PV shunts and 21 had no shunt),

and 53 patients without cirrhosis who underwent the repair

of umbilical hernias. Among the cirrhotic patients, mortality

was significantly higher in the group with uncontrolled

ascites (8.3%) than either the group with functioning PV

shunts (0%) or in the group without cirrhosis (0%). The

recurrence rate was significantly higher in the group with

uncontrolled ascites (17%) compared to the group with

controlled ascites (0%) and the group without cirrhosis (0%).

Finally, Runyon and Juler [14] retrospectively reviewed

the records of patients undergoing umbilical herniorrhaphy

at their institution between 1973 and 1983. They identified

22 patients who had a history of ascites. There were no

operative deaths, but morbidity consisting of wound

infections and leakage of ascitic fluid from the wound

occurred in 18% of patients. Five of these patients were

lost to follow-up. All patients in this series had only

medical control of ascites and, of the remaining 17 patients

available for analysis, 11 had uncontrolled ascites at the

time of hernia repair. Eight of these patients developed

recurrent hernias after an average follow-up of 2 years.

Among the six patients who had successful medical control

of their ascites, there was only one recurrence.

These controlled studies strongly suggest that the

absence of ascites is critical to the success of umbilical

herniorrhaphy. Taken as a group, of the 49 patients in these

studies with uncontrolled ascites, 22 suffered recurrences of

their umbilical hernias. In contrast, of the 47 patients who

did have successful control of their ascites, only two had

recurrent hernias. When the recurrence rates form these

studies are simply pooled together without adjustment, this

yields a RR ratio of 10.55 (95% confidence interval [CI]

3.12–39.7). A meta-analysis of these three papers was

performed to derive a summary estimate as well (Fig. 2).

This provided an adjusted pooled RR ratio of 8.51 (95% CI

2.69–26.9) using Mantel–Haenszel methods. This figure

should be interpreted cautiously, however, since the studies

were not randomized and there may be other confounding

factors which influenced the selection of procedures to

control ascites and which may have influenced the success

of these procedures. In addition, two of the papers used PVS

as the procedure to control ascites, which is used less often

today due to complications [15]. Alternative techniques to

control ascites such as temporary peritoneal drains would

not be expected to provide as long a duration of control over

Fig. 2 Meta-analysis of the

effect of uncontrolled ascites on

umbilical hernia recurrence

rates

466 Hernia (2009) 13:461–468

123

ascites as a PVS, so it remains to be seen whether the long-

term recurrence rates would be as good as with PVS.

Several uncontrolled case series were also identified in

our review. In the vast majority of these case series, the

ascites was controlled successfully. Of 35 patients reported

in these series who had successful control of ascites, only

one developed a recurrent hernia. This rate is quite favor-

able in comparison to past reports, where recurrence has

been as high as 71% in the presence of uncontrolled ascites

[8, 14].

The survey results also support the use of adjunctive

procedures to control ascites at the time of hernia repair.

The majority of respondents (69%) stated that they would

consider a concomitant procedure for the ascites. The

likelihood of offering such a procedure increased with

increasing Child’s status, which would correlate with the

increasing severity of ascites (Table 4). A peritoneal dia-

lysis catheter or drain until adequate wound healing has

occurred was the preferred option, although some would

consider serial percutaneous drainage, PVS, or TIPS.

It should be noted, however, that some have reported

excellent recurrence rates in cirrhotics, even in the pres-

ence of ascites. In one series of 15 cirrhotics with between

1 and 4 l of ascitic fluid at the time of hernia repair with

prosthetic mesh, there were no recurrences after a mean

follow-up of 32 months [16].

In summary, it is generally agreed that the control of

postoperative ascites is critical to the long-term success of

umbilical hernia repair [17]. Although one series reported

excellent recurrence rates in cirrhotics in the presence of

ascites, many of the patients may have had only mild to

moderate ascites [16]. Several interventions to control

ascites have been described in addition to medical man-

agement, such as TIPS, PVS, peritoneal dialysis catheters or

drains, and serial percutaneous drainage. There is insuffi-

cient evidence to recommend one of these methods over any

other, but it does appear that some form of intervention to

control ascites is warranted. The proper duration of tech-

niques such as peritoneal drainage is unknown. Risks of

long-term peritoneal drainage such as infection and loss of

protein-rich ascitic fluid must be weighed against the risk of

hernia recurrence in this situation.

Limitations

The main limitation of this study is that the treatment

recommendations are based on low levels of evidence.

Although an extensive literature search was done, no pro-

spective studies were identified and there is no Level I or II

evidence available. Most studies were case series and a few

were retrospective cohort studies. The relative rarity of this

condition would make it very difficult to prospectively

recruit significant numbers of patients, and randomizing

such patients to treatments would likely create ethical

dilemmas. This leaves surgeons to rely on only a few small

retrospective series. The survey was conducted in order to

increase the ability to make treatment recommendations for

this patient population, but such results only constitute

expert opinion, which is a low level of evidence. It must be

kept in mind that the number of respondents was low, as

less than 50% of surgeons replied and, of those who did,

only 40% answered all of the survey questions. This fact is

a further limitation to the study results. Nevertheless, this

study attempts to make general recommendations for the

surgical treatment of umbilical hernias in cirrhotic patients

with ascites.

Conclusions

While acknowledging the limitations of this study, it

appears that the early repair of umbilical hernias in patients

with cirrhosis and ascites is safer than it was in the past and

can be considered for selected patients. This may avoid

increased morbidity and mortality associated with urgent

repair later on. The control of ascites is critical to a suc-

cessful outcome. Urgent repair of umbilical hernia in cir-

rhotic patients is indicated when complications develop.

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