In the absence of portal hypertension, we have found that patients with liver disease respond similarly to the stress of general anesthesia and surgery as other patients with abdominal wall hernias. In these patients, our surgical approach is consistent with our standard of care, which is a retromuscular hernia repair with permanent mesh for larger defects (>10 cm in width) and laparoscopic repair for smaller defects (<10 cm in width).

Our surgical technique has been previously described and will not be detailed here [21, 22]. However, the type of mesh used during these repairs is important and will be discussed briefly. Historically, general surgeons have been hesitant to use permanent mesh in patients with chronic liver disease due to the risk of potential coinfection should the patient develop spontaneous bacterial peritonitis at any point postoperatively. Nevertheless, there are no studies that have supported this belief [23]. Furthermore, the proposed benefits of biologic mesh utilization, including increased resistance to infection and long-term durability, have not held true [24]. Because of the high-risk nature of these patients, all precautions should be taken to provide for a durable, long-term hernia repair. Current literature supports permanent large pore synthetic mesh in this regard, which is why we prefer to use this type of mesh in these patients. In addition, placing the mesh extraperitoneally can facilitate less adhesiolysis during future liver transplantation,

In the presence of portal hypertension, the degree of hepatic dysfunction is important. If esophageal or intra-abdominal varices or thrombocytopenia are present, the extent of hepatic dysfunction is almost certainly severe. For these patients, delineating the presence of symptoms as well as overlying skin changes such as dermal thinning is important to determining appropriate management. In the absence of obstructive symptoms or skin changes, patients should be treated with an abdominal binder and referral to a hepatologist for management of their portal hypertension. On the other hand, patients with obstructive symptoms or worrisome skin findings require surgical intervention.

The surgical approach to symptomatic patients with portal hypertension varies based on the degree of portal hypertension. For patients with new-onset portal hypertension without associated varices or thrombocytopenia, a retromuscular repair with permanent mesh is often performed. On the other hand, for patients with more advanced disease, an onlay, extraperitoneal approach with permanent mesh is used. This approach requires less manipulation of intra-abdominal tissues than our standard retromuscular approach, which therefore reduces the risk of surgical hemorrhage or postoperative liver decompensation in these higher-risk patients.

As previously mentioned, the development of ascites cannot occur without the presence of portal hypertension [12]. This means that patients with ascites are inherently at a higher risk for surgery than patients with portal hypertension alone. The option for surgical intervention in patients with ascites, therefore, is rarely discussed during the first clinical visit. Rather, these patients are referred to a hepatologist for medical management of their liver disease through the use of a beta-blocker, a salt-restricted diet, and aldosterone antagonists. Once patients with portal hypertension or portal hypertension with ascites are medically optimized in the opinion of a hepatologist, these patients are considered for surgery based on the extent of their remaining symptoms.

Similar to our approach to abdominal wall hernias in patients with CLD, our approach to groin hernias in this patient population is based largely on our own experience. Although these patients remain a high-risk population, the risk of inguinal hernia surgery is significantly lower than that of abdominal wall surgery as inguinal hernias can be repaired without the use of a general anesthetic. Therefore, we recommend the repair of all groin hernias in this patient population. It has been our experience that the laparoscopic approach to inguinal hernia repair in patients with CLD is taught with an increased risk of hemorrhage in the retroperitoneum and does not afford similar benefits such as earlier return to work as seen in patients without CLD. We therefore recommend an open primary tissue repair for inguinal hernias if the defect is small or a Lichtenstein repair with only mesh if the defect is large.

Patients with chronic liver disease are at high-risk of developing abdominal wall and groin hernias. Despite its frequency, the ideal approach to hernia repair in this patient population remains unknown. In order to minimize the risk of perioperative decompensation, a multidisciplinary approach for the management of a patient’s chronic liver disease, perioperative optimization, and surgical repair on an elective basis should be employed.