From the Journals

Consider timing and technique before hernia repair in patients with cirrhosis



Herniorrhaphy may be appropriate in compensated cirrhosis but only when accompanied by careful selection of patients, operative timing, and technique, according to a literature review of studies on hernia management in cirrhosis.

Surgeons operating monkeybusinessimages/Thinkstock

“Hernia management in cirrhosis continues to be restricted by lack of high-quality evidence and heterogeneity in expert opinion,” wrote lead author Sara P. Myers, MD, of the University of Pittsburgh, and her coauthors, adding that “there is, however, convincing evidence to advocate for elective ventral, umbilical, or inguinal hernia repair in compensated cirrhosis.” The study was published in the Journal of Surgical Research.

After reviewing 51 articles – including 7 prospective observational studies, 26 retrospective observational studies, 2 randomized controlled trials, 15 review articles, and 1 case report – Dr. Myers and her colleagues organized their data into three categories: preoperative, intraoperative, or postoperative considerations.

From a preoperative standpoint, decompensated cirrhosis was recognized as a “harbinger of poor outcomes.” Signs of decompensated cirrhosis include ascites, variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. A 2006 study found that patients with decompensated cirrhosis survive for a median of less than 2 years, while those with compensated cirrhosis has a median survival of more than 12 years.

Intraoperative considerations leaned on studies of cholecystectomy; the evidence suggested that patients with mild to moderate cirrhosis can undergo laparoscopic surgery, even showing decreased risk of mortality, pneumonia, sepsis, and reoperation as a result. And although most laparoscopic procedures involve an intraperitoneal onlay mesh repair and the “use of mesh for hernia repair in patients with cirrhosis has been debated,” a 2007 study showed that synthetic mesh is safe for elective herniorrhaphy.

Finally, they shared specific postoperative risks, including encephalopathy and ascites, along with the fact that cirrhosis itself “precipitates immune dysfunction and deficiency and promotes systemic inflammation.” At the same time, they highlighted a 2008 study in which a cohort of 32 patients with cirrhosis underwent elective Lichtenstein repair with no major complications and an overall improved quality of life.

The coauthors noted that, although many surgeons will avoid hernia repair in patients with severe liver disease because of the associations with high morbidity and mortality, dissent fades when an emergency means abstaining will lead to a prognosis worse than intervention. That said, when it comes to preemptive elective repair there are also “no clear guidelines with regard to severity of cirrhosis and thresholds that would preclude herniorrhaphy.” Regardless of the choices made, “recognizing and managing complications in cirrhotic patients who have undergone hernia repair is crucial,” they wrote.

The authors reported no conflicts of interest.

SOURCE: Myers SP et al. J Surg Res. 2018 Oct 23. doi: doi: 10.1016/j.jss.2018.09.052.

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