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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 3
| Issue : 3 | Page : 87-93 |
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Inguinal hernia repair in cirrhotic patients with ascites
Junsheng Li, Xiangyu Shao, Tao Cheng, Zhenling Ji
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| Date of Submission | 31-Mar-2020 |
| Date of Decision | 06-Apr-2020 |
| Date of Acceptance | 30-Apr-2020 |
| Date of Web Publication | 20-Aug-2020 |
Correspondence Address:
Prof. Junsheng Li
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing 210009
China
 Source of Support: None, Conflict of Interest: None  | 2 |
DOI: 10.4103/ijawhs.ijawhs_11_20
AIM: Cirrhotic patients with ascites have a high incidence of abdominal wall hernias and carry an elevated perioperative morbidity and mortality. The optimal surgical treatment as well as timing of inguinal hernia repair in this situation remains controversial. In the present study, we aim to address the safe and risk profile of inguinal hernia repair in cirrhotic patients with ascites.
MATERIALS AND METHODS: Major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies published through October 2019 were identified, using the keywords: “inguinal hernia,” “liver cirrhosis,” “ascites,” “hernia repair,” including various combinations of the terms, all relevant articles and reference lists in these original studies were also obtained from the above databases.
RESULTS: Nine articles were identified on inguinal hernia repair in cirrhotic patients with ascites. Various anesthetic methods and repair techniques were used to repair inguinal hernia in this situation. The frequent postoperative complications were minor-wound complications, with an overall incidence of 15.4% in elective surgery, which could be managed with conservative treatment. While, emergent surgery was associated with increased wound complications. The recurrence rate was 2.0%, the average of postoperative 30-day mortality was 1.0%, and none of the death was attributable to the complications of inguinal hernia repair and their treatment.
CONCLUSION: Elective inguinal hernia repair in cirrhotic ascites is safe and should be advocated. Emergent surgery is associated with increased wound complications. Although the data are insufficient to support a specific technique, mesh repair has advantages with regard to long-term recurrence rate.
Keywords: Ascites, complication, inguinal hernia, liver cirrhosis, repair
How to cite this article:
Li J, Shao X, Cheng T, Ji Z. Inguinal hernia repair in cirrhotic patients with ascites. Int J Abdom Wall Hernia Surg 2020;3:87-93 |
| Introduction | |  |
Abdominal wall hernia is common in patients with ascites, and several factors contribute to the development of abdominal hernia in this situation, including malnutrition, increased abdominal pressure, and peritoneal distension, which frequently weaken the abdominal muscle and fascia.[1] The most common cause of ascites in the United States is liver cirrhosis, which accounts for 80% of cases with ascites,[2] the presence of cirrhotic ascites is associated with poor quality of life, an increased risk of infection, an increased risk of hepatorenal syndrome, and a poor prognosis.[3],[4],[5] It has been estimated that, umbilical hernias are present in 20% of patients with cirrhosis, compared to 3% of the population at large.[6] Although the incidence of inguinal hernia in cirrhotic patients, especially combined with ascites, is expected to be higher than in the normal population, the exact incidence and natural history of inguinal hernia in liver cirrhosis with ascites, as well as the postoperative outcome and clinical course of these patients have not been well documented.
It has been reported that the perioperative mortality was similar between cirrhotic and noncirrhotic patients, but emergent operation was associated with a higher mortality compared to elective repair.[7] Furthermore, patients with cirrhosis were also at an increased risk of hernia incarceration, strangulation, and hernia recurrence.[8] Since cirrhotic patients with ascites have a limited life expectancy; therefore, an expectant approach for the management of inguinal hernia in cirrhotic patient with ascites was proposed,[9] and elective hernia repair without liver transplantation has not usually been performed if the ascites was not under control with medical or surgical therapy. However, others reported that inguinal hernia repair in ascitic patients was safe and effective.[10],[11]
In addition, because of the limited number of patients in each study on inguinal hernia repair with ascites, and the mixed outcomes of inguinal hernia and umbilical hernias/incisional hernias in each study,[8],[12],[13],[14],[15] the optimal timing and method for inguinal hernia repair in patients with liver cirrhosis and ascites are still debating.[12] The objective of the present study is to gain further insight into the clinical course and outcomes of inguinal hernia repair in cirrhotic patients with ascites.
| Materials and Methods | | |
Major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies published through October 2019, using the keywords: inguinal hernia, liver cirrhosis, ascites, hernia repair, including various combinations of the terms, were reviewed. Abstracts were reviewed to confirm relevance, and then the full articles were extracted. All relevant articles and reference lists in these original studies were also obtained from the above databases. IRB approval and written consents are not needed for this type of study.
Inclusion criteria
All studies retrieved and summarized in the present study were published as full-length articles in peer-reviewed journals. Studies include trials that reported the outcomes of inguinal hernia repair in cirrhotic patients with ascites.
Exclusion criteria
The search results were carefully assessed to exclude studies involving only umbilical hernia, incisional hernia, or ventral hernia repair procedures. Studies that containing inguinal hernias, but the outcomes were not separately reported from other abdominal wall hernias were also excluded. Ascites from etiology other than cirrhosis were excluded. Review articles and articles not available in the English language were also excluded.
| Results | | |
Nine articles[9],[11],[16],[17],[18],[19],[20],[21],[22] on inguinal hernia repair in cirrhotic ascites patients were retrieved from the electronic databases for the final review and analysis. [Figure 1] shows a flowchart of studies from the initial results of the publication searches to the final inclusion or exclusion. The details of the nine articles are presented in [Table 1]. As shown in [Table 1], the included trials contained five retrospective studies, two case reports, one prospective study, and one case-control study. | Table 1: The overall data of the trials on inguinal hernai repair in the cirthotic patients with ascites
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Anesthesia types and hernia repair approaches
Different anesthesia methods and inguinal hernia repair techniques have been reported in the nine studies, the anesthesia methods included local, spinal, and general anesthesia [Table 1]. The hernia repair approaches in the present study consisted of primary hernia repair methods (Bassini, Mcvay),[9],[18] Lichtenstein technique,[11],[21] mesh-plug technique,[17] transabdominal preperitoneal approach (TAPP),[22] and total extraperitoneal (TEP) repair.[20] In one study, the inguinal hernia repair procedure was reported only as “mesh” or “no mesh,”[19] and in another study, the exact procedure was not clear.[16] Open inguinal hernia repair procedures were reported in seven studies. Drainage was selectively used in three studies with the indication of large surgical dead space or refractory ascites,[11],[18],[21] in five studies, the drainage was not used at all.[9],[17],[19],[20],[22]
Postoperative complications after elective surgery
The most frequent postoperative complications after inguinal hernia repair in cirrhotic patients with ascites were minor wound complications, including wound hematoma, seroma, and swelling. The average incidence of wound complications was 15.4% (range from 0 to 18%) in the elective surgery [Table 1]. These minor wound complications could be successfully managed conservatively. Mild encephalopathy or prerenal azotemia was reported in two studies.[9],[16] One study[16] reported three cases of elective open inguinal hernia repair under spinal anesthesia, and two of the three cases developed esophageal hemorrhage, one of them patient died, and another patient received liver transplantation, and the third patients also developed encephalopathy and received liver transplantation thereafter.
Postoperative complications after emergent surgery
In contrast to elective surgery, the wound complication rate increased dramatically after emergent surgery, as reported that in one study, 72.7% (8/11) of the patients returned to operation room after emergent surgery for surgical site infection (SSI), hematoma, or seroma, although no mesh removal was needed [Table 1].
Of note, there was no ascites leakage in both elective and emergent surgeries. The overall recurrence rate after inguinal hernia repair in cirrhotic patients with ascites was 2.0% in the present study, ranged from 0[11],[16],[20],[21],[22] to 8%,[9] with the longest follow-up of 4 years [Table 1].
Quality of life after inguinal hernia repair
Quality of life was evaluated in one study by a Short-Form-36 Questionnaire, and a clear improved quality of life was observed.[11]
Mortality and survival
The average of postoperative 30-day mortality in the present study was 1.0% [Table 1]. The causes of death were attributed to the deterioration of liver disease, none of the death was related to the complications of inguinal hernia repair and their treatment. One-year mortality of 36.4% was reported in one study,[17] and three studies reported the 2-year mortality, ranged from 6.7% to 47.1 (average of 24.1%)[9],[20],[21] [Table 1].
| Discussion | | |
Patients with liver cirrhosis and ascites exhibit peritoneal distension and frequently develop herniation of the weakest structures in the abdominal wall. These patients usually have significant symptoms because when fluid retention increases, ascites enter into the hernia sac in both the standing and recumbent position, consequently, the hernia becomes enlarged and painful.[11] The incidence of inguinal hernia in cirrhotic patients with ascites is expected to be higher than in the normal population, but the treatment of inguinal hernia in the presence of liver cirrhosis with ascites is still a matter of debate.
Patients with liver cirrhosis and ascites are more likely to present the several disorders of metabolism involving various organ functions, including thrombocytopenia, coagulopathy, portal hypertension, renal failure, and are often associated with an increased risk of postoperative liver decompensation, as well as an impairment of wound healing due to the malnutrition state.[23],[24]
Conflicting results have been reported in literature regarding abdominal wall hernia repair in the presence of cirrhotic ascites. In general, elective abdominal wall hernia repair has been discouraged because of the high morbidity and mortality in cirrhotic patients; furthermore, the refractory ascites pose an important risk factor for complications and recurrence.[9] Horn et al.[25] reported that hernia repair in patients with advanced portal hypertension and ascites should treated conservatively whenever possible, due to the increased risk of postoperative complications of infection, recurrence, and ascites leakage. Furthermore, refractory ascites have also been considered as a major risk factor for the hernia repair surgery and the relapse.[6]
However, a much higher mortality would be anticipated if the cirrhotic patients were repaired for emergency since patients with cirrhotic ascites usually do not easily tolerate bowel obstruction or strangulation from incarcerated inguinal hernia.[6]
Studies in literature often reported mixed results of different types of hernias, including umbilical hernias, incisional hernias, and inguinal hernias;[8],[10],[12] thus, the results and suggestions in these studies would not reflect the situation of inguinal hernia repair, which is a relative less traumatic surgery and could be even managed with local anesthesia. For this purpose, in the present study, the repair of inguinal hernia in the presence of cirrhotic ascites was analyzed.
Some surgeons advocated elective surgery in decompensated cirrhosis and observed comparable surgical risk or recurrence.[26] Many recent studies show that elective surgery should be proposed to improve the quality of life of these patients without significantly increasing the postoperative complications.[11]
In the present study, 208 patients were included, and the results indicated that the overall postoperative complication rate was low, and most of the complications were minor wound complications, especially wound hematoma, with an overall rate of 15.4% [Table 1], which that the impaired coagulation and the malnutrition were responsible for the main postoperative complications. Therefore, coagulopathy is the major concern for the surgeons.[27] Of note, all the wound complications in the elective surgeries could be successfully managed conservatively. However, one study reported the results of emergent surgery, 72.7% (8/11) of the emergent cases underwent inguinal hernia repair returned operation room for the treatment of SSI, hematoma, or seroma,[19] which highlighted the higher postoperative wound complication rates after emergent surgeries.
In the present study, there were no ascites leakage, no deep infection, and no mesh removal; furthermore, the overall recurrence rate was 2%, although esophageal hemorrhage occurred in two cases of the 208 patients (0.96%).[16] Our present study revealed that the 30-day postoperative mortality rate was 1% after inguinal hernia repair, and which was not repair-procedure related, but due to the evolution of cirrhotic disease. The average of 2-year mortality was 24.1% in this study [Table 1], which suggests that approximate three quarters of the patients were alive for 2 years; therefore, an elective surgery is advocated to improve the patient's quality of life[11] and to avoid the increased complications-associated emergent surgeries.[19]
Although different types of anesthesia and surgical repair techniques have been reported in the present study patients with cirrhosis often have limited hepatic reserve and tolerate physiologic stress poorly, the surgical procedures performed on these patients should intend not to increase the anesthetic and surgical complications. Unlike other abdominal wall hernia repairs, inguinal hernia could be easily managed under local anesthesia, thus, the use of local anesthesia for inguinal hernia repair appeared to be a preferable technique for inguinal hernia repair in patients with cirrhosis accompanied by ascites. We have routinely performed elective inguinal hernia repairs under local anesthesia in cirrhotic ascitic patients in our clinic, and the patient tolerated well, there was no recurrence, mesh infection, and perioperative death.
In the present study, mesh repair with either the technique of “mesh-plug,” “Lichtenstein” or TAPP or TEP was reported, and no mesh removal was required. It seems that although superficial infections and wound complications can be accounted, the present study showed that the use of mesh in both elective and emergency inguinal hernia repair in patients with ascites was not contraindicated. We consider that the use of mesh is quite appropriated for these patients, because it reduces the incidence of recurrence, due to the fact that the healing process is impaired in cirrhotic patients. Recently, the international guideline recommended that, similar to patients who undergo surgery for prostate cancer, those with ascites are considered difficult to treat and should undergo Lichtenstein repair.[28]
There are several limitations in the present study: first: the total number of patients is small; second: different techniques were used in these studies, including both open and laparoscopic procedures; third: most of the studies were retrospective, and there is no randomized comparative studies; therefore, the prospective, randomized controlled trials are needed in future to give robust evidence for surgeries in this specific condition.
| Conclusion | | |
Elective repair of symptomatic inguinal hernia in cirrhotic ascites is safe and should be advocated. Emergent surgery is associated with increased wound complications. There is an insufficient quality of the studies supporting a special technique, but mesh repair may have some advantages with respect to long-term recurrence rate.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1]
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