|Year : 2017 | Volume
| Issue : 4 | Page : 372-379
Repair of uncomplicated umbilical hernia in cirrhotic patients: experience of an institute
Ashrf El-Kholy A Othman MD
Department of Surgery, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
|Date of Submission||17-Apr-2017|
|Date of Acceptance||16-Jun-2017|
|Date of Web Publication||13-Nov-2017|
Ashrf El-Kholy A Othman
Department of Surgery, National Hepatology and Tropical Medicine Research Institute, Cairo, 13111
Source of Support: None, Conflict of Interest: None
The objective of this study was to present experience of a single institute in the management of uncomplicated umbilical hernia (UH) in cirrhotic patients.
Patients and methods
The study included 232 patients with UH: 103 patients class A, 83 Child–Pugh class B, and 46 Child–Pugh class C. Ascites was mild in 46 patients, moderate in 80 patients, and severe in seven patients, whereas 99 patients had no ascites. All patients underwent classic repair with proline mesh insertion if required.
A total of 71 patients had direct defect closure and 161 patients had mesh repair. Operative time was significantly longer in class C patients than other classes and in patients of class B than class A. Peritoneal drainage was required in 109 patients with significantly higher frequency in class C. ICU admission was required in 33 patients with significantly higher frequency and longer duration in patients of class C. Duration of subcutaneous wound drainage was significantly longer, frequency of patients who developed short-term postoperative complications was significantly higher and hospital length of stay was significantly longer for patients of class C. During the follow-up for 23.2±7.9 months, 23 patients developed recurrent UH with significantly higher frequency in class C than other classes. Recurrence rate was significantly lower with mesh repair than direct closure (6.8 vs. 16.9%). During follow-up, 14 (6%) patients died secondary to causes not related to surgery with significantly higher in class C.
Elective UH repair in cirrhotic patients is feasible and is associated with acceptable rate of postoperative complications and no surgery-related mortalities. Mesh repair significantly reduced the recurrence rate. The pronounced outcome of patients of class A points to the necessity of early repair of UH to get the benefit of hepatic reserve and minimal volume of ascetic fluid.
Keywords: cirrhotic patients, mesh repair, morbidities, mortalities, recurrence, uncomplicated umbilical hernia
|How to cite this article:|
Othman AKA. Repair of uncomplicated umbilical hernia in cirrhotic patients: experience of an institute. Egypt J Surg 2017;36:372-9
|How to cite this URL:|
Othman AKA. Repair of uncomplicated umbilical hernia in cirrhotic patients: experience of an institute. Egypt J Surg [serial online] 2017 [cited 2018 Nov 15];36:372-9. Available from: http://www.ejs.eg.net/text.asp?2017/36/4/372/218163
| Introduction|| |
The underlying etiologies for umbilical hernia (UH) development in cirrhotic patients include weakness of muscles of the anterior abdominal wall secondary to poor nutrition  and recanalized umbilical vein induces restoration of supraumbilical fascial defect . In such patients’ population, UH was exaggerated when longstanding ascites is present leading to increased intra-abdominal pressure. The high intra-abdominal pressures when applied to areas of parietal weakness causes hernia formation and/or enlargement .
Surgical repair of UH in ascetic patients is a challenge  with high anesthetic and surgical risk . However, permanent mesh can be used in hernias in cirrhotic patients with minimal wound-related morbidity and a significantly lower recurrence rate (RR) ,. Thus, the current study aimed to present the experience of a single institute in the management of uncomplicated UH in cirrhotic patients.
| Patients and methods|| |
The current prospective comparative study was conducted at the General Surgery Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt, since June 2012 till June 2016. The study protocol was approved by the Local Ethical Committee. Inclusion criteria included patients with varying degrees of liver dysfunction and presented with uncomplicated UH. Patients with complicated UH, compromised respiratory functions, or hernia at other abdominal wall orifices were excluded from the study. Patients fulfilling inclusion criteria or their near relatives signed fully informed written consent for study participation and undergoing the assigned surgical procedure.
All patients underwent clinical examination to assure diagnosis and inclusion criteria. Ascites was graded according to definitions of the International Ascites Club  as three grades (grades 1–3) according to the extent of ascites and the method for detection using ultrasound or clinical examination ([Table 1]).
|Table 1 Criteria and score points for calculation of Child–Pugh score |
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Patients underwent preoperative estimation of serum albumin and total bilirubin levels and international normalized ratio, and then they were classified according to the Child–Turcotte–Pugh scoring system  into three classes: class A: 5–6 points, class B: 7–9 points, and class C: 10–15 points. The risk for developing 3-month mortality was calculated using the model for end-stage liver disease (MELD) score which is based on the etiology of cirrhosis and laboratory variables .
No special preoperative preparation was needed for class A cases. For patients of classes B and C, hepatic function support, control of ascites, and reduction of portal vein pressure reduction so as to allow class C patients to near class B level for safer elective surgery; on the other side, associated comorbidities were also controlled.
General anesthesia using sevoflurane was applied if general condition and results of liver function tests permit; otherwise, local infiltration anesthesia in conjunction with intravenous anesthetic infusion was used. All patients received prophylactic broad-spectrum antibiotic prior to skin incision. All patients were assigned for classic repair with proline mesh insertion according to requirement with wound drainage. Peritoneal drainage was provided if indicated to relieve abdominal pressure to allow wound healing.
Immediate postoperative (PO) care was conducted at postanesthetic care unit unless there is an indication for admission to ICU as delayed recovery, development of respiratory embarrassment, or if patient was preoperatively at risk of cardiac or cerebrovascular accident.
Collected operative data included operative time, amount of operative bleeding, the frequency of patients had mesh insertion, and if it was onlay or sublay, the frequency of peritoneal drainage. Immediate PO data included the frequency of ICU admission and length of stay (LOS). Short-term PO data included duration of wound drainage, frequency of patients developed wound infection, seroma and duration of peritoneal drainage. During follow-up for at least 6 months, the frequency of patients developed recurrence or other surgery-related morbidities and/or mortality were recorded.
The obtained data were presented as mean±SD, ranges, numbers, and ratios. Results were analyzed by one-way analysis of variance and χ2-test using the SPSS (version 15, 2006; SPSS Inc., Chicago, Illinois, USA) for Windows statistical package. P value less than 0.05 was considered statistically significant.
| Results|| |
The study included 232 cirrhotic patients with UH; 103 (44.4%) patients were Child–Pugh (CP) class A, 83 (35.8%) patients were CP class B, and 46 (19.8%) patients were of CP class C. There was nonsignificant (P>0.05) difference between the studied patients as regards age, sex, and frequency of additional morbidities. Patients of class C had a significantly higher BMI compared with patients of class A (P1=0.001) and class B (P2=0.004) with significantly (P1=0.027) higher BMI of patients of class B than class A. Patients of class A had a significantly (P1=0.001) lower MELD score than patients of other classes with significantly (P2=0.001) lower score of patients of class B than class C. A total of 91 (42.7%) patients had no ascites and all were of Child class A; 46 (19.8%) patients had mild ascites; 80 (34.5%) patients had moderate ascites; and only seven (3%) patients had severe ascites. The frequency of patients had ascites grade 3 among patients of class C which was significantly (P1 and P2<0.001) higher compared with patients of class A (P1<0.001) and class B (P2<0.001) with significantly (P1<0.001) higher frequency among patients of class B than class A. Details of enrollment data of studied patients are shown in [Table 2].
A total of 118 (50.9%) patients received local anesthesia; 72 patients of class B and 46 patients of class C, whereas the other 114 (49.1%) patients received general anesthesia. Mean diameter of the umbilical defect, in its greatest dimension, was 3.5± range: 1–6 cm with significantly wider defect in patients of class C than patients of class A (P1=0.002) and class B (P2=0.047) and nonsignificantly (P>0.05) wider defect in patients of class B than patients of class A. Totally, 71 (30.6%) patients had anterior abdominal wall muscles of appropriate strength and small umbilical defects that allowed direct defect closure without the need for mesh application. The frequency of patients who required mesh repair was significantly higher among patients of class C compared with patients of classes A (P1<0.001) and B (P2<0.001) with significantly (P1<0.001) higher frequency among patients of class B compared with class A. A total of 14 patients, nine of class B and five of class C, received sublay mesh insertion followed by muscle approximation, so as to minimize ascetic fluid loss; the frequency of patients required sublay mesh was significantly higher in patients of classes B and C than those of class A. A total of 147 patients received onlay mesh with a significantly higher frequency among patients of classes B and C compared with patients of class A ([Figure 1]).
|Figure 1 Patients’ distribution according to the use of mesh for defect closure.|
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No patient of class A required peritoneal drainage, whereas 109 patients, 63 (75.9%) patients of class B and 46 (100%) patients of class C, required peritoneal drainage to lessen the intra-abdominal pressure so as to allow wound healing with significantly higher frequency of peritoneal drainage among patients of class C than patients of class B (P2=0.0003).
The mean amount of operative blood loss was 177±42; range: 105–350 ml with nonsignificantly (P>0.05) higher amounts of blood loss in patients of class C than patients of the other classes. Mean operative time was 65.7±10; range: 45–90 min operative time was significantly (P1 and P2=0.001) longer for patients of class C compared with patients of the other classes and significantly (P1=0.001) longer operative time in patients of class B than class A ([Table 3] and [Figure 2]).
|Table 3 Operative data of studied patients categorized according to Child–Pugh class|
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|Figure 2 Mean operative time for hernial repair of studied patients categorized according to Child–Pugh class.|
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Thirty-three (14.2%) patients required ICU admission for a mean duration of 2.3±0.7; range: 1–4 days. The frequency of ICU admission among patients of class C was significantly (P2=0.0005) higher than patients of class B with nonsignificantly (P>0.05) longer duration of ICU stay ([Table 4]).
|Table 4 ICU data of studied patients categorized according to Child–Pugh class|
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Mean duration of subcutaneous wound drainage was significantly longer in patients of class C compared with that of patients of class A, whereas in patients of class B, duration of wound drainage showed a nonsignificant (P>0.05) difference compared with patients of other classes. A total of 129 (55.6%) patients developed short-term PO complications for a frequency of 1.4 complications per affected patient. The frequency of PO complications was significantly higher in patients of class C compared with patients of classes A (P1=0.001) and B (P2=0.013). Moreover, the frequency of PO complications was significantly (P1=0.001) higher among patients of class C (1.46/patient) than patients of other classes (0.5/patient in class A and 0.68/patient in class B). On the contrary, the frequency of PO complications was nonsignificantly (P>0.05) higher among patients of class B than class A ([Figure 3]). Mean hospital LOS was significantly longer for patients of class C compared with those of classes A and B (P1 and P2=0.001) with significantly longer duration for patients of class B (P1=0.001) than patients of class A ([Table 5]).
|Figure 3 Frequency of postoperative short-term outcome of patients categorized according to Child–Pugh class (☆: significant vs. class C).|
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|Table 5 Short-term postoperative data of studied patients categorized according to Child–Pugh class|
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Mean duration of follow-up was 23.2±7.9; range: 6–42 months with nonsignificant (P>0.05) difference between patients of the three classes. A total of 23 patients developed recurrent UH throughout follow-up period for a total RR of 9.9%. However, the frequency of recurrence was nonsignificantly higher among patients of class C compared with patients of classes A and B (P1 and P2 >0.05), with nonsignificantly (P1>0.05) higher frequency of recurrence among patients of class B than patients of class A. Moreover, the RR was significantly (P=0.006) lower among patients who had mesh repair (6.8%) than those who had direct closure (16.9%) as shown in [Figure 4]. Unfortunately, 14 patients died throughout the follow-up period for a frequency of 6%; but no patient died secondary to surgical complication. Mortality rate was significantly higher among patients of class C compared with patients of class A (P1=0.002), but was nonsignificantly (P2>0.05) higher compared with class B and nonsignificantly (P1>0.05) higher mortality rate among patients of class B than class A ([Table 6]).
|Table 6 Follow-up postoperative data of studied patients categorized according to Child–Pugh class|
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| Discussion|| |
The current study included 232 cirrhotic patients presented with uncomplicated UH; to illustrate the outcome of surgical repair, patients were categorized according to Child–Turcotte–Pugh grading and the outcome for each class was illustrated and compared. In line with this, de Goede et al.  and Kotb et al.  documented that preoperative MELD and CP scores appeared to be predictive of PO risks in patients with liver cirrhosis who undergo nonhepatic surgery.
The frequency of patients had ascites grade 3 was significantly higher among patients of class C than patients of other classes and this was reflected clinically as significantly higher BMI and wider umbilical defect and could define a relation between ascetic fluid volume and severity of heniation; similarly Wang et al.  reported that the volume of ascites and CP scores had positive correlations with UH.
A total of 23 (9.9%) patients developed recurrent UH with significantly higher RR among class C patients than patients of other classes and among patients who had direct closure (16.9%) versus patients who had mesh repair (6.8%). In support of these data, Youssef and El Ghannam  reported an RR of 10% with mesh repair and 35% with direct repair of UH in ascetic patients. Besides, Eker et al.  reported an RR of 7% after UH repair. Recently, Winsnes et al.  reported cumulative RR of 8.4% and Coelho et al.  found hernia repair with mesh is associated with lower RR than direct repair of UH in a cirrhotic patient.
The mean operative time (65.7±10 min) was significantly longer for patients of class C compared with patients of the other classes with significantly longer operative time in patients of class B than class A. In line with this finding, Hassan et al.  studied 70 cirrhotic patients who underwent elective sublay UH mesh repair and reported a mean operative time of 67.45 min. Besides, Kotb et al.  reported significant difference in operative time among patients of the three CP classes and was longest in group C when compared with the other two groups.
Short-term PO complications were reported in 129 patients for a frequency of 1.4/patient with significantly higher frequency of PO complications and significantly higher frequency per patient in class C than in classes A and B. Similarly, Youssef and El Ghannam  reported early PO ascitic fluid leakage in 15%, and mild superficial wound infection in 25% of patients had mesh repair, whereas in patients who had direct repair ascitic leakage occurred in 30% and wound infection in 15%. Besides, Choi et al.  and Lasheen et al.  reported an overall complication rate of 42 and 30%, respectively, after elective repair of UH in ascetic patients.
On contrary to these results, Hassan et al.  reported wound infection in 2.8%, seroma in 4.2%, ascitic fistula in 1.4%, and recurrence in 1.4% of patients and Kotb et al.  reported no recurrence, no morbidities after a 6-month follow-up; however, such discrepancy could be attributed to their small sample size (n=70 and 40 patients, respectively) and short duration of follow-up (6 months).
The mean hospital LOS was significantly longer for patients of class C compared with those of classes A and B with significantly longer duration for patients of class B than class A. Similarly, Kotb et al.  reported significant difference in hospital stay among patients categorized according to CP classes.
During follow-up, 14 (6%) patients died secondary to causes unrelated to surgery with significantly higher mortalities among patients of class C. In line with the reported figure, Eker et al.  and Choi et al.  reported a mortality rate of 7 and 6.2%, respectively, after elective UH repair in patients with liver cirrhosis. Similar to the obtained results, Kotb et al.  and Eker et al.  reported no surgery-related mortality in their series of ascetic patients underwent UH repair.
One point of discrepancy in the literature is to operate or not on UH in cirrhotic patients especially if ascetic; the current study illustrates the beneficial outcome of hernial repair of uncomplicated UH, irrespective of the severity of hepatic derangement as judged by preoperative investigations and clinical evaluation and expressed as CP class and allow rejecting the traditional concepts regarding operative decision in cirrhotic patients especially if ascetic. In support of such opinion, multiples previous studies ,,,,, have documented that early repair of UH in cirrhotic patients is safer than it was in the past and can be considered for selected patients to safeguard against the increased morbidity and mortality associated with urgent repair later on.
| Conclusion|| |
The obtained results and review of literature allowed to conclude that elective UH repair in cirrhotic patients is feasible and is associated with acceptable rate of PO complications and no surgery-related mortalities. Mesh repair improves outcome as significant reduction of RR. The pronounced outcome of patients of class A points to the necessity of early repair of UH to get the benefit of hepatic reserve and minimal volume of ascetic fluid. However, there was no definite contraindication for repair of UH in patients of classes B and C and PO peritoneal drainage helps healing of the repair site.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Dokmak S, Aussilhou B, Belghiti J. Umbilical hernias and cirrhose. J Visc Surg 2012; 149(Suppl 5):e32–e 39.
Shlomovitz E, Quan D, Etemad-Rezai R, McAlister VC. Association of recanalization of the left umbilical vein with umbilical hernia in patients with liver disease. Liver Transpl 2005; 11:1298–1299.
Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis 1997; 17:219–226.
Loriau J, Manaouil D, Mauvais F. Management of umbilical hernia in cirrhotic patients. J Chir (Paris) 2002; 139:135–140.
Guriță RE, Popa F, Bălălău C, Scăunașu RV. Umbilical hernia alloplastic dual-mesh treatment in cirrhotic patients. J Med Life 2013; 6:99–102.
Chatzizacharias NA, Bradley JA, Harper S, Butler A, Jah A, Huguet E et al.
Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol 2015; 21:3109–3113.
Ammar SA. Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia 2010; 14:35–38.
Arroyo V, Ginès P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G et al.
Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996; 23:64–176.
Fischer SP, Bader AM, Sweitzer B. Preoperative evaluation. In: Miller RD, Eriksson LI, Wiener-Kronish JP, editors. Miller’s anesthesia. 7th ed. Philadelphia: Churchil Livingstone Elsevier; 2009. 1027.
Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PCJ. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31:864–871.
De Goede B, Klitsie PJ, Lange JF, Metselaar HJ, Kazemier G. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol 2012; 26:47–59.
Kotb MB, Abdel-Malek MO, Eltayeb AA, Makhlouf GA, Makhlouf NA. Button hole hernioplasty: a new technique for treatment of umblical hernia in cirrhotic patients. A prospective follow up study. Int J Surg. 2015; 24(Part A):64–69.
Wang R, Qi X, Peng Y, Deng H, Li J, Ning Z et al.
Association of umbilical hernia with volume of ascites in liver cirrhosis: a retrospective observational study. J Evid Based Med 2016; 9:170–180.
Youssef YF, El Ghannam M. Mesh repair of non-complicated umbilical hernia in ascitic patients with liver cirrhosis. J Egypt Soc Parasitol 2007; 37 (Suppl 3):1189–1197.
Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA et al.
A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery 2011; 150:542–546.
Winsnes A, Haapamäki MM, Gunnarsson U, Strigård K. Surgical outcome of mesh and suture repair in primary umbilical hernia: postoperative complications and recurrence. Hernia 2016; 20:509–516.
Coelho JC, Claus CM, Campos AC, Costa MA, Blum C. Umbilical hernia in patients with liver cirrhosis: a surgical challenge. World J Gastrointest Surg 2016; 8:476–482.
Hassan AM, Salama AF, Hamdy H, Elsebae MM, Abdelaziz AM, Elzayat WA. Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites. Int J Surg 2014; 12:181–185.
Choi SB, Hong KD, Lee JS, Han HJ, Kim WB, Song TJ et al.
Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy. Dig Liver Dis 2011; 43:991–995.
Lasheen A, Naser HM, Abohassan A. Umbilical hernia in cirrhotic patients: outcome of elective repair. J Egypt Soc Parasitol 2013; 43:609–616.
McKay A, Dixon E, Bathe O, Sutherland F. Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia 2009; 13:461–468.
Yu BC, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. Ann Surg Treat Res 2015; 89:87–91.
Andraus W, Pinheiro RS, Lai Q, Haddad LB, Nacif LS, D’Albuquerque LA, Lerut J. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg 2015; 15:65.
Banu P, Popa F, Constantin VD, Băllău C, Nistor M. Prognosis elements in surgical treatment of complicated umbilical hernia in patients with liver cirrhosis. J Med Life 2013; 6:278–282.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]