Laparoscopic Incisional and Umbilical Hernia Repair in Cirrhotic Patients Giulio Belli, MD, Alberto D’Agostino, MD, Corrado Fantini, MD, Luigi Cioffi, MD, Andrea Belli, MD, Nadia Russolillo, MD, and Serena Langella, MD Background: Traditional approach to incisional hernias (IHs) in cirrhotic patients is plagued by a significant recurrence rate and frequent wound infections. The laparoscopic repair of IHs was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. In cirrhotic patients there are additional reasons for the benefits of laparoscopy. First, preservation of the abdominal wall avoids interruption of large collateral veins. Second, nonexposure of viscera restricts electrolytic and protein losses, and improves absorption of ascites. Finally, the laparoscopic approach is associated with a lower perioperative blood loss (smaller abdominal incision). Methods: A retrospective review was performed for 14 consecutive patients with ventral hernias and affected by chronic hepatitis or cirrhosis related to hepatitis C-B virus, who underwent laparoscopic repair at our institution between September 2002 and October 2004. All patients were in class A of Child-Pugh classification. Results: There was no conversion to open operation. The mean size of the defects was 87 cm 2 (range 1 to 480); incarceration was present in 2 patients and multiple (Swiss-cheese) defects in 1. In all cases, the mesh (average, 287 cm 2 ) was secured with transabdominal sutures and metal tacks or staples leaving the sac in situ. Operative time and estimated blood loss averaged 88 min (range 18 to 270) and 30 mL (range 10 to 150). Length of hospital stay averaged 2.6 days (range 1 to 6). There were 11 minor complications: seroma lasting >4 weeks (5), post- operative ileus (2), suture site pain >2 weeks (2), urinary retention (1), and skin breakdown (1). We experienced no recurrences with an average follow-up of 8 months (range 3 to 24). Conclusions: Laparoscopic IH repair is technically feasible and safe even in cirrhotic patients with fascial defects. This operation decreases postoperative pain, shortens the recovery period, and seems to reduce postoperative morbidity and recurrence. To the best of our knowledge, this is the first report in which a series of cirrhotic patients affected by incisional and umbilical hernias is treated with a laparoscopic approach. Key Words: incisional hernia, laparoscopic, cirrhotic (Surg Laparosc Endosc Percutan Tech 2006;16:330–333) T raditional approach to incisional hernias (IHs) in cirrhotic patients is plagued by a significant recur- rence rate as well as frequent wound infections. 1,2 Thus, liver cirrhosis is a major determinant of postoperative morbidity and mortality. 3 Persistent ascites, along with increased intra-abdominal pressure, may lead to hernia- tion of the abdominal content through a congenital latent defect of the abdominal wall. The prevalence of umbilical hernia in cirrhotic patients with ascites is up to 20%, and the recurrence rate after umbilical herniorrhaphy in those patients has been reported to be as high as 60%. 4–6 A laparoscopic approach to hernia repair, with a lower recurrence rate and fewer complications than the open approach, has found favor among surgeons. 7–12 Based on our previous experience on laparoscopic liver resection for hepatocellular carcinoma on cirrhosis, 13–15 we started to treat umbilical and ventral IH in cirrhotic patients. We report our experience of the last 2 years. METHODS From September 2002 to October 2004, information on all patients undergoing laparoscopic repair of ventral hernia at Department of General and Hepato-bilio- pancreatic surgery of Loreto Nuovo Hospital (Naples, Italy) was prospectively entered into a database. A total of 37 patients underwent laparoscopic repair, of those 14 had chronic hepatitis or cirrhosis related to hepatitis C-B virus. From the whole series, in this study we focused our attention on the 14 cirrhotic patients analyzing methods and outcomes from this subgroup. Diagnosis of cirrhosis was biopsy-proven in 10 patients, in 2 was made with serologic and US findings. Two patients had chronic hepatitis. In 5 patients esophagogastroduodenoscopy put in evidence initial esophageal varices (grade F1). Child class was A for all of them. In all patients, age, sex, body mass, index, operating room time, fascial defect size, mesh type and size, number and type of transfixation sutures used, previous surgery performed, length of hospital stay, conversion rate, and complications were recorded. Recurrence was determinated by focused history and physical examination in the immediate Copyright r 2006 by Lippincott Williams & Wilkins Received for publication August 3, 2005; accepted April 15, 2006. From the Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Naples, Italy. Reprints: Giulio Belli, MD, via Cimarosa 2a, 80127, Naples, Italy (e-mail: chirurgia.loretonuovo@tin.it). ORIGINAL ARTICLE 330 Surg Laparosc Endosc Percutan Tech  Volume 16, Number 5, October 2006