Perioperative risks and risk factors in patients with cirrhosis undergoing abdominal wall hernia repair: a population-level analysis

Background — Abdominal wall hernias are common in patients with cirrhosis and associated with increased perioperative risk. Our objective was to describe the perioperative outcomes and risk factors in a contemporary population of patients with cirrhosis undergoing hernia repair.

Methods — A retrospective, population study on adult patients with cirrhosis undergoing abdominal wall hernia surgery in Ontario between 2009 and 2018. Outcomes included 90-day mortality, postoperative liver decompensation events, complications, and blood transfusions. Adjusted relative risks were estimated from Poisson regression models for mortality and postoperative liver decompensation events.

Results — We identified 6,040 adults with cirrhosis who underwent hernia repair (inguinal, n = 2,494; umbilical, n = 1,199; ventral/incisional, n = 1,893; incarcerated, n = 454). Median age was 61 years, 76% were male, and 79% underwent elective operation. Overall mortality was 4% (15.5% for emergency repair, 1.1% for elective). Factors associated with 90-day mortality were age, hepatitis C or alcohol-associated cirrhosis, Charlson Comorbidity Index, emergent operation, Model for End-Stage Liver Disease-Sodium, and noninguinal hernia. In those undergoing elective surgery, factors associated with mortality included age, Charlson Comorbidity Index, hepatitis C, ventral/incisional hernia, and Model for End-Stage Liver Disease-Sodium. Factors associated with increased risk of 90-day postoperative liver decompensation events included a history of previous liver decompensation and Model for End-Stage Liver Disease-Sodium score. Complications occurred in 12.5% (23.8% emergency, 9.5% elective); surgical-site infection (15.0% and 4.8%), venous thromboembolism (2.4% and 0.7%), and blood product transfusion (42.4% and 4.7%).

Conclusion — Emergency hernia repair in patients with cirrhosis is associated with increased complications, including an 8-fold increased risk of mortality, compared to elective surgery. These data support elective hernia repair in most patients with cirrhosis, taking into consideration age, other comorbidities, cirrhosis etiology and severity.