TIPSS as therapeutic modality for umbilical hernia in patients with advanced liver disease.

Abstract

TIPSS, transvenous intrahepatic portosystemic shunting. The recent editorial by McAlister1 reviewed the therapy of umbilical hernia in patients with advanced liver disease in response to the publication by Sarit et al.2 regarding the dual Gortex mesh laparoscopic repair of recurrent umbilical hernias. This prompted us to review our experience in similar patients. Although this excellent editorial reviewed the available surgical and medical options extensively, including outlining an algorithm for the management, we would like to add another therapeutic modality, TIPSS (transvenous intrahepatic porto-systemic shunting), which was not discussed in the treatment algorithm. Umbilical hernias in patients with advanced cirrhosis are almost always associated with and are likely to be a consequence of portal hypertension. Hernia repairs, regardless of specific surgical methods, do not correct portal hypertension. As a result of this, these hernias frequently recur and lead to multiple surgical hernia repairs. These patients with advanced liver disease are usually followed by hepatologists or gastroenterologists and not by surgeons. We report our experience in patients with advanced liver disease who were not liver transplant candidates. These patients had 5 to 8 umbilical hernia repairs, despite which symptomatic umbilical hernias recurred. In these selected patients TIPSS was performed. We had 5 cases of patients with umbilical hernias, which persisted despite multiple mesh repairs (ranging from 3–5 per patient). These patients had been repeatedly seen by emergency room and other physicians for umbilical hernia-related symptoms. All five patients had local skin breakdown and poor quality of life because of the hernia; however, none had refractory ascites. TIPSS was considered specifically for the therapy of the umbilical hernia. All 5 patients had resolution of their umbilical hernias for a follow-up of 6 months to 5 years and the nonrefractory ascites resolved, as expected, after TIPSS. Two patients, in particular, had recurrence of their umbilical hernia as an early indicator of TIPSS stenosis, which resolved on dilatation of TIPSS. These 2 patients also had caput medusae present around the umbilical hernia, which disappeared after TIPSS but returned when it was stenosed. This implies that portal hypertension, especially collaterals in the umbilical region, may play a significant role in the pathogenesis of umbilical hernias and supports Dr. McAlister's hypothesis. Other patients with umbilical hernia who underwent TIPSS for refractory ascites and variceal bleed also had a significant resolution of their umbilical hernia after TIPSS. Also, in our experience, our patients with umbilical hernia who were transplant candidates did not require separate repair of the umbilical hernia after successful liver transplantation in most cases. We wanted to share our experience to highlight the availability of TIPSS as a treatment option for patients with advanced liver disease as a therapy for recurrent umbilical hernia, even without refractory ascites. Jasmohan Singh Bajaj*, Rajiv R. Varma*, * Division of Gastroenterology and Hepatology Medical College of Wisconsin Milwaukee, WI.