Patient Optimization is the Key in Surgical Repair of Ruptured Umblical Hernia in Cirrhotic Patients and Tense Ascitis

Background: Ulceration, leakage, and rupture are considered as the most common complications of umbilical hernias in patients with refractory ascites due to advanced cirrhosis. We aim to determine optimal management and outcome after umbilical herni- orrhaphy or hernioplasty in those patients. Methods: A retrospective chart review was performed on 37 patients with advanced cir- rhosis who underwent umbilical herniorrhaphy or hernioplasty at our hospital. Results: A total of 37 patients (12 female, 32.4%) had refractory ascites, with mean age of 52.2 ± 7.7 years (ranging from 37 to 70 years), 30 presented with leaking fluid, 5 with ulceration, and only 2 with spontaneous umbilical rupture. A total of 33 (89.2%) required perioperative human albumin transfusion, and only 7 (18.9%) required perioperative paracentesis. Only five patients (13.5%) required preoperative platelets transfusion. Propylene mesh was used in seven (18.9%) cases. Eleven patients (29.7%) developed ascites-related wound complications. Leaking ascites was recorded in three cases (8.1%) and only one case (2.7%) developed wound dehiscence and required reoperation. Hematemesis and melena were recorded in three (8.1%) early post operative without renal deterioration or encephalopathy. No early postoperative mortality. Conclusion: With meticulous preoperative patient optimization, management of rup- tured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible.


Introduction
About 14% of all Egyptian population were tested positive for antibodies against hepatitis C virus (HCV), indicating that these individuals have been infected with the RNA hepatitis C virus at some point [1]. However, only 10% of the population is considered as carriers for the viral RNA and is chronically infected. It was estimated that about half a million people are newly infected every year [2]. Ascites is a common complication of cirrhosis [3]. Cirrhosis is common with alcohol abuse and hepatitis virus infection [4]. Raised intraabdominal pressure leads to umbilical hernia in 20% of those patients [5]. Surgery for patient with liver cirrhosis is considered a "difficult field" because of many factors, such as deficiency in protein synthesis and coagulation disorders, in addition to respiratory and lung disease or cardiac dysfunction associated with late stages [6]. Complications of umbilical hernias in those patients with cirrhosis and tense refractory ascites include ulceration, leakage, incarceration, and rupture [7].
Flood syndrome, or spontaneous umbilical hernia rupture, is an important complication of longstanding tense ascites and end-stage liver disease [8]. Rupture may follow a sudden increase in intraabdominal pressure such as vomiting, coughing, and straining of stool [9]. The spontaneous rupture and evisceration is usually preceded by other factors such as inflammation that weaken the hernia covering [10,11].
Other factors which can contribute to the rupture of a hernia are friction by the patient's external corset or abdominal support, and lack of adhesions between the bowel and the hernial sac allowing the bowel to act as a hammerhead upon the skin [12]. Irrespective of the pathogenesis of the ventral hernia, a factor that increases the risk of rupture is delayed repair of the defect [10,11]. Unfortunately, many surgeons are reluctant to perform elective repairs because of the risk of increasing operative mortality [10]. However, this attitude exposes those patients to more risk of rupture or impending rupture announced by skin ulceration or a sudden increase in the size of the hernia [13].
Because nonsurgical management of a ruptured umbilical hernia has a mortality rate of 60-80% after supportive care [14], operative management either by local tissue repair or mesh repair is recommended [9]. Hemodynamic instability and even death may be precipitated by the loss of a massive quantity of ascites [15]. To assume portal decompression, transjugular intrahepatic portosystemic shunt (TIPS) can be used for a better control of the ascites that may allow these patients to undergo surgery [7]. The management of these patients requires a multidisciplinary approach, and a delay leads to higher recurrence, morbidity, and mortality [5].
The aim of our study is to evaluate the outcome of these patients during emergency situation to determine the optimal management after umbilical herniorrhaphy or hernioplasty in patients with advanced cirrhosis and refractory ascites to minimize the morbidity and mortality in such cases.

Patient and method
Thirty-seven consecutive cases of patients with liver cirrhosis and tense ascites treated in the surgery department of Mansoura University Emergency Hospital with ruptured or impeding rupture of ventral hernia were reviewed. Exclusion criteria including complicated cases with strangulated bowel, and those operated electively with normal skin covering.
The average age of the study group was 52.28 years, with a male:female ratio of 2.08:1, 25 men and 12 women. Presentation of hernia that required surgery was: 30 presented with leaking fluid, 5 with ulceration, and only 2 with spontaneous umbilical rupture. Thirty-three (89.2%) patients required perioperative human albumin transfusion, and only seven (18.9%) required perioperative paracentesis. Only five patients (13.5%) required preoperative platelets transfusion.
Surgical procedures were practiced under local anesthesia (32 cases), or spinal anesthesia (5 cases). A total of thirty cases were managed by using a two-layer repair technique and 7 cases of interrupted sutures using polypropylene and additional layer of polypropylene mesh. Intraabdominal closed drain and another subcutaneous suction drain were applied routinely. Patients were followed for 30 days postoperatively in outpatient clinic and after that either in the outpatient or using phone calls and complications were recorded in these patients, see Table 1.

Results
All the patients of the study group were followed and quantified for early and late postoperative complications. There were no death in the early first 30 days postoperatively, see A seroma, hematoma, or wound infection have been noted in 11 (29.7%) cases, and required only a local treatment. Ascites fluid leakage appeared in three cases (8.1%) and was treated by diuretics, albumin transfusion, and ascites drainage. It did not need any surgical intervention. However, complete dehiscence and rupture of the repair occurred only in one case (2.7%) and required reoperation in the 10th postoperative day, see Table 2.
On contrary to our expectation, systemic complication in the form of hepatorenal failure or death did not occur in any case. However, three cases of postoperative hematemesis and melena were recorded. Only one patient needed endoscopic ligation of active variceal bleeding beside antisecretory and hemostatic treatment and blood transfusion; other two cases were diagnosed as mild erosive gastritis and responded well to antisecretory and hemostatic treatment and blood transfusion. One patient presented a dynamic ileus, treated by a nasogastric tube and correcting electrolyte imbalance. ICU admission for the treatment of electrolyte imbalance, early signs of encephalopathy, or bleeding varices was needed in six cases (16.2%) but without any mortality. Late complications as hernia recurrence was recorded in only one case (2.7%) after 8 months of surgery, see Table 3.

Discussion
Incidence of hernia in cirrhotics with ascites is 20% [5,16]. Literature is scarce about spontaneous rupture of hernia [10]. Delay in seeking treatment or neglect for early operative intervention increases the risk of rupture [17]. Unfortunately, many surgeons are reluctant to perform elective repairs because of the risk of increasing operative mortality [10] (see Figure 1). The delay in repair carries the risk of more protrusion and attenuation of the covering by ischemia from pressure and stretching [10], resulting in erosion, ulceration, and rupture. Delayed surgical management of cirrhotic patients with umbilical hernia and ascites is associated with elevated rate of grave complications, and carries the risks of more mortality and morbidities as incarceration, evisceration, ascites drainage, and peritonitis [18] (see Figure 2). Other reports found increase in mortality with complicated hernias [11,18]. However, elective umbilical herniorrhaphy is safe and effective in most cirrhotic patients in which ascites is adequately controlled [19] (see Figures 1 and 2).
Other studies have also suggested elective umbilical herniorrhaphy in cirrhotic patients and described superior results over conservative management to avoid complications associated with this kind of management [20,21].
The treatment of cirrhotic patients with umbilical hernia is still controversial [22]. Indication, timing, and technical aspects of herniorrhaphy in these patients also remain controversial [20].
Hernia repair in these patients remains a procedure with a high morbidity and mortality rate if it is performed in emergency conditions due to the occurrence of complications [23].  Medical treatment of ascites with diuretics, sodium restriction, and paracentesis should be the first step in the management. Effective ascites control reduces complications, such as wound infection, evisceration, ascites drainage from the wound, and peritonitis [24].
In our study group after exclusion of complicated cases with strangulation and bowel resection, it was noted that local wound problem persisted in 29.7%, and systemic problem in the form of attack of hematemesis and melena in three cases only (8.1%), with no cases of hepatorenal and no mortality. ICU admission for six patients (16.2%) is not a complication and helps our team for better ascites control and to avoid development of encephalopathy. These facts denote that hernia repair procedure alone is not a risky procedure even during emergency situation. Urgent aggressive control of ascites and herniorrhaphy or hernioplasty has near or the same results of elective repair in these patients.

Conclusion
With meticulous preoperative patient optimization and good ascites control, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible, and safe procedure even during emergency situation, mortality reported by other authors belongs mainly to complications of the hernia especially strangulation, and to less extent evisceration. Finally all data enforce the opinion that encourage surgical repair of the hernia once diagnosed on elective base or even during emergency, and avoid waiting complications, especially strangulation, and subsequent possible bowel resection which carries the main cause for mortality in these patients. More study is needed to determine the risk factors and may be a new score to predict mortality in these patients.