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Description
A male patient in his mid-30s with end stage alcoholic cirrhosis (Child-Pugh C, MELD 21) was referred to our hospital due to refractory ascites. He had had several hospital admissions for spontaneous bacterial peritonitis, encephalopathy and sepsis. He was submitted to an emergency herniorraphy due to a strangulated umbilical hernia. Suddenly the surgical suture did not hold the intra-abdominal pressure and the ascitic fluid erupted through the surgical suture in a fountain-like way (figure 1). The patient died a few days later.
Fountain-like eruption of ascitic fluid through the suture dehiscence.
Learning points
Umbilical hernias are very common in cirrhotic patients, and their management carries several challenges. One should be aware that:
▶ Early repair is safer than it was in the past and can be considered for selected patients, preferably Child A status.
▶ In those with refractory ascites consideration of a transjugular intrahepatic portosystemic shunt before the elective herniorraphy1 is a valid option with potential to avoid the morbidity and mortality associated with repair in the emergency setting.
▶ Uncontrolled ascites appears to be strongly predictive of hernia recurrence2 but a permanent mesh can be used in complicated hernias in cirrhotic patients, with minimal wound-related morbidity and a significantly lower rate of recurrence.3
▶ Urgent repair of umbilical hernia in cirrhotic patients is only indicated when serious complications develop, such as a strangulated hernia or rupture, bearing in mind that in these particular cases great care should be held to control the ascites in the perioperative period to prevent complications such as leakage, eruption (as in our case) or recurrence of the hernia.
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.