Ask the Experts - Inguinal Hernia Repair in Patient With Liver Failure?
I have a patient with newly diagnosed, compensated liver failure (ascites controlled with diuretic therapy, Child's Class A) and an inguinal hernia that is symptomatic. What is the best type of repair in these patients? Are the statistics about mortality after these simple procedures true?

Marc Neff, MD

Patients with cirrhosis complicated by ascites often develop inguinal or umbilical hernias. In general, an operation to repair such a hernia should not be undertaken unless there is evidence of incarceration or the patient complains of severe symptoms (usually pain) that are refractory to nonoperative management. A binder (for an umbilical hernia) or a truss (for an inguinal hernia) will often temporize the symptoms.

There are no randomized studies indicating which type of repair is best for inguinal herniorrhaphy. However, if a hernia repair is required, then several guidelines are recommended. First, ascites should be controlled by abdominal catheter drainage or diuretics before surgical repair. Second, if present, the coagulopathy and thrombocytopenia should be corrected as best as possible. This usually entails transfusion of platelets and fresh frozen plasma at the start of the surgery. Third, it is advisable not to open the peritoneal hernia sac, but to reduce the hernia and construct the repair over it, because the hernia sac can easily tear and will leak ascites fluid into the subcutaneous tissues and wound. There is also no consensus in the literature regarding the use of prosthetic mesh. Some series do describe hernia repairs with the use of a prosthetic graft.

Regarding morbidity and mortality from the procedure, the general principle is that the sicker the patient, the greater the risk. In 1 series, the operative mortality after hernia repair was 5%, and these deaths occurred in Child's Class C cirrhotics. Life-threatening liver failure after inguinal herniorrhaphy in patients with cirrhosis has been reported.