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Incarcerated Umbilical Hernia after Large Volume

Paracentesis for Refractory Ascites
Christos K Triantos1, Ioannis Kehagias2, Vasiliki Nikolopoulou1, Andrew K Burroughs3
1) Department of Gastroenterology, University Hospital, Patras; 2) Department of Surgery, University Hospital, Patras,
Greece; 3) The Royal Free Sheila Sherlock Liver Centre and Dept. of Surgery, UCL and Royal Free Hospital, London,
UK

Fig 1 a, b. CT scan of the abdomen: large umbilical hernia with incarcerated bowel.

A 42-year-old Caucasian male with cirrhosis due to

alcohol abuse and HCV infection was having repeated 4-5 L
paracenteses, increasing in frequency to twice monthly, over
31 months. Following the last paracentesis, he developed
nausea, umbilical pain and a tender, warm non-reducible
umbilical mass. A CT scan confirmed a large umbilical hernia
with incarcerated bowel and ascites (Figs. 1 a,b).
He underwent emergency surgery. The incarcerated loop
of small bowel was ischaemic but viable, so no resection
was necessary, and the hernia spontaneously reduced. A two
layered prosthetic mesh of polypropylene and PTFE was
placed to reinforce the abdominal wall. After two days the
patient was discharged in a good clinical condition.
The prevalence of umbilical hernia in patients with
cirrhosis and ascites is as high as 20%, with recurrence rates
after repair as high as 60% [1]. Common complications
include leakage, ulceration, rupture and incarceration. There
are only three case reports associating incarceration with
paracentesis [1-3]. The removal of ascitic fluid following
paracentesis causes decreased tension on the umbilical hernia
ring, which can lead to incarceration.
Management of umbilical hernias in cirrhotic patients
with ascites remains difficult as they often have advanced
liver disease and are at increased risk of complications
following any surgical intervention. Elective surgical repair
prevents complications, whereas mortality after emergency
surgery is up to 30%. Mesh repair has lower recurrence rates
J Gastrointestin Liver Dis
September 2010 Vol. 19 No 3, 245

than standard repair [4]. Optimal control of ascites before

repair is essential and transjugular intrahepatic portosystemic
stent shunt (TIPS) may be needed. TIPS can reduce the
rate of re-accumulation of ascites, and also reduces portal
hypertension. If liver transplantation is likely in the near
future, repair can take place at the same time.
Patients with cirrhosis and umbilical hernias should be
referred for a surgical opinion to be considered for elective
repair. Repair should be performed after optimal management
of ascites, which includes fluid and salt restriction, diuretics
and possibly a TIPS procedure before surgery, if the ascites
is difficult to control with diuretic therapy [5].

References
1. Baron HC. Umbilical hernia secondary to cirrhosis of the liver.
Complications of surgical correction. N Engl J Med 1960; 263:824828.
2. Chu KM, McCaughan GW. Iatrogenic incarceration of umbilical
hernia in cirrhotic patients with ascites. Am J Gastroenterol 1995;
90:2058-2059.
3. Touze I, Asselah T, Boruchowicz A, Paris JC. Abdominal pain in a
cirrhotic patient with ascites. Postgrad Med J 1997; 73:751-752.
4. Ammar SA. Management of complicated umbilical hernias in
cirrhotic patients using permanent mesh: randomized clinical trial.
Hernia 2010;14:35-38.
5. Triantos C, Kehagias I, Nikolopoulou V, Burroughs AK. Surgical
repair of umbilical hernias in cirrhosis with ascites. AJMS 2010 (in
press).