Management in patients with liver cirrhosis and an umbilical hernia Hendrik A. Marsman, MD, a Joos Heisterkamp, MD, PhD, a Jens A. Halm, MD, PhD, a Hugo W. Tilanus, MD, PhD, a Herold J. Metselaar, MD, PhD, b and Geert Kazemier, MD, PhD, a Rotterdam, the Netherlands Background. Optimal management in patients with umbilical hernias and liver cirrhosis with ascites is still under debate. The objective of this study was to compare the outcome in our series of operative versus conservative treatment of these patients. Methods. In the period between 1990 and 2004, 34 patients with an umbilical hernia combined with liver cirrhosis and ascites were identified from our hospital database. In 17 patients, treatment consisted of elective hernia repair, and 13 were managed conservatively. Four patients underwent hernia repair during liver transplantation. Results. Elective hernia repair was successful without complications and recurrence in 12 out of 17 patients. Complications occurred in 3 of these 17 patients, consisting of wound-related problems and recurrence in 4 out 17. Success rate of the initial conservative management was only 23%; hospital admittance for incarcerations occurred in 10 of 13 patients, of which 6 required hernia repair in an emergency setting. Two patients of the initially conservative managed group died from complications of the umbilical hernia. In the 4 patients that underwent hernia correction during liver transplantation, no complications occurred and 1 patient had a recurrence. Conclusions. Conservative management of umbilical hernias in patients with liver cirrhosis and ascites leads to a high rate of incarcerations with subsequent hernia repair in an emergency setting, whereas elective repair can be performed with less morbidity and is therefore advocated. (Surgery 2007;142:372-5.) From the Department of Surgery a and Department of Gastroenterology and Hepatology, b Erasmus MC, Rotterdam, the Netherlands Patients with liver cirrhosis complicated with ascites have a risk of 20% of developing an umbilical hernia in the course of their disease. 1 The factors that contribute to the development of an um- bilical hernia in these patients are as follows: in- creased intra-abdominal pressure from the ascites formation, weakness of the abdominal fascia and muscle wasting as a result of poor nutritional status, and the dilated umbilical vein enlarging the preexis- tent supra-umbilical fascial opening in patients with portal hypertension. 2 The optimal treatment of an umbilical hernia in cirrhotic patients is not clear. Common surgical knowledge states that operative correction of an um- bilical hernia in patients with ascites should not be performed and that a “wait and see” approach is often preferred because of expected high operative risks and high recurrence rates after repair. 3-5 Conserva- tive management, however, can be complicated by incarceration or spontaneous rupture from necrosis of overlying skin, forcing an emergency repair in patients who are at greater risk of complications after such operations than after elective operation. Currently the natural course of umbilical hernias in patients with ascites is unknown as are studies that compare elective correction with conservative man- agement. Only anecdotal reports of successful primary or secondary umbilical hernia repair exist in the litera- ture on which a choice for 1 of the 2 treatment strategies can hardly be based. 6-8 The objective of this study was to evaluate the results of management of umbilical hernias in patients with concurrent ascites and liver cirrhosis in order to define optimal hernia treatment. PATIENTS AND METHODS The patient records of our institution between the period 1990 and 2004 were screened using the Accepted for publication May 3, 2007. Reprint requests: Geert Kazemier, Department of Surgery, 10M, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, the Nether- lands. E-mail: g.kazemier@erasmusmc.nl. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.05.006 372 SURGERY