Umbilical Hernia Incarceration Following Ascitic Decompression: A Report of Two Cases

Abstract

Purpose: Umbilical hernias are frequently noted in patients with cirrhosis particularly in those with significant ascites. In cirrhotics who have diuretic resistant ascites, decompression procedures such as large volume paracentesis (LVP) or transvenous intrahepatic portosystemic shunting (TIPS) are indicated. Reports in the literature documenting incarceration of umbilical hernias after LVP or TIPS are rare. We report two such cases. Case 1 is a 77-year-old female with Child-Pugh Class B alcoholic cirrhosis. Two days after a LVP, she developed an incarcerated umbilical hernia and underwent emergent resection of 15 centimeters of ischemic gangrenous bowel. Case 2 is a 65-year-old male with Child-Pugh Class B Hepatitis C cirrhosis. Twenty days after a TIPS stent revision (due to stent thrombosis), the patient presented emergently with an incarcerated umbilical hernia and underwent surgical management. Umbilical hernia incarceration should be recognized as a potential complication following LVP and TIPS procedures. Generally, as long as the fascial defect remains widely patent (perhaps by the tension produced from ascitic fluid) such hernias are easily reducible. However, if the tension on the fascial opening decreases or the opening itself becomes smaller, bowel present in the hernial sac could incarcerate and subsequently strangulate. It remains unclear whether it is the amount of fluid or the rate of fluid removed that leads to the increased risk of hernia incarceration. Cirrhotics are high risk surgical candidates. In cases of emergent incarcerated hernia repair, an even higher morbidity and mortality can be expected. Thus, cirrhotics should be aggressively screened and recommended to have elective repair of hernias.Figure: Case 1Figure: Case 2