The American Journal of Surgery (2008) 196, 373–378

Clinical Surgery-International

Inguinal hernioplasty improves the quality of life in

patients with cirrhosis
Rosalia Patti, M.D.a, Piero Luigi Almasio, M.D.b, Salvatore Buscemi, M.D.a,
Fausto Famà, M.D.a, Antonio Craxì, M.D.b, Gaetano Di Vita, M.D.a,*

a
General Surgery Unit, Department of Surgical and Oncological Sciences, University of Palermo, Via Liborio Giuffrè n°
5, 90100 Palermo, Italy; bGastrointestinal and Liver Unit, University of Palermo, Italy

KEYWORDS: Abstract
Cirrhosis; BACKGROUND: The optimal management of symptomatic inguinal hernia (SIH) in cirrhotics is still
Hernia; undefined. Both hernia and cirrhosis impair quality of life (QOL). The aim of this study was to evaluate
Quality of life QOL by a Short Form-36 (SF-36) questionnaire in cirrhotic patients undergoing inguinal hernioplasty.
METHODS: Thirty-two cirrhotic patients undergoing inguinal hernioplasty were evaluated. They
were classified according to Child’s class and to the absence or presence of refractory ascites. The
SF-36 questionnaire was administered the day before and 6 months after surgery. Global analyses of
the 8 domains of SF-36 and of 2 comprehensive indexes of SF-36, Physical Component Summary
(PCS) and Mental Component Summary (MCS), were performed.
RESULTS: Lichtenstein hernioplasty for SIH originated no major complications. All 8 domains of
SF-36 and MCS and PCS scores improved remarkably after hernioplasty especially in patients in
Child’s class C and/or with refractory ascites.
CONCLUSIONS: Inguinal hernioplasty for SIH in patients with cirrhosis is a safe procedure. The
improvement of QOL represents a clear cut indication for elective hernia repair.
© 2008 Elsevier Inc. All rights reserved.

The incidence and natural history of inguinal hernias
(IHs) in cirrhotic patients are not fully described.1 Because
of the limited number of patients in each study and their
heterogeneity in terms of functional class, it is difficult to
assess the risk of complications of untreated IH in cirrhotic
patient, even though life-threatening sequelae, such as stran-
gulation, are relatively uncommon.2 Because patients with
liver cirrhosis have on average a limited life expectancy, an
expectant approach for the management of IH in these
patients has been recommended.3
* Corresponding author. Tel. ⫹39-091-655-2606; fax: ⫹39-091-655-
2646.
E-mail address: divitagaetano@libero.it
Manuscript received January 7, 2008; revised manuscript February 28,
2008
Up to one third of patients affected by IH are asymp-
tomatic or have only mild symptoms from their hernia,4 the
most common being moderate pain that does not affect their
working or leisure activities.5 By converse, patients with
advanced decompensated cirrhosis usually have severe
symptoms because, when fluid retention increases, ascites
enter into the hernial sac both in the standing position and
when recumbent. The hernia is then enlarged and often
painful; it may hamper deambulation and frequently
forces the patient to stay in bed. Over the last years,
evaluation of the quality of life (QOL) in patients with
chronic degenerative diseases has achieved a central role
in management and decision making because the main
goal of care has been refocused on maintaining the long-
est possible time of being disease free from invalidating
symptoms.

0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2008.02.007
374 The American Journal of Surgery, Vol 196, No 3, September 2008
Both hernia and cirrhosis may affect the QOL of patients.
Different questionnaires have been used to evaluate QOL.
Among them, the brief version of Medical Outcome Study,
a short form with 36 answers (SF-36), is the most used. The
SF-36 has been used to measure and validate QOL both in
cirrhotics and in patients with IH, but only 1 study has
evaluated QOL in cirrhotic patients undergoing hernio-
plasty.6 In this study, all patients stated that hernia operation
improved their QOL after discharge, but the methodology
of investigation and the relation with the stage of progres-
sion of liver disease are not fully reported.
In this study, we administered pre- and postoperatively an
Italian version of the SF-36 questionnaire7,8 to all patients with
cirrhosis of various etiologies classified according to Child’s
class and the absence or presence of refractory ascites admitted
to our unit for a Lichtenstein hernioplasty because of a symp-
tomatic inguinal hernia (SIH) in order to evaluate prospec-
tively the effect of surgery on their QOL.
Patients and Methods
Thirty-two consecutive patients with cirrhosis and SIH
were included in this prospective study from November
2002 to November 2006 (Fig. 1). They had been admitted to
the Gastrointestinal and Liver Unit to evaluate their func-
tional hepatic status and subsequently referred to the Gen-
eral Surgery Unit to perform a Lichtenstein hernioplasty in
order to get symptomatic relief. All patients gave written
informed consent, and the local ethics committee approved
Figure 1 Diagram that shows the recruitment of patients.
the study. None of these subjects, at the time of hospital-
ization, had complications of the inguinal hernia symptom-
atic, but all were symptomatic. Exclusion criteria were the
presence of a large umbilical hernia, hepatocellular carci-
noma, or severe heart disease. All patients underwent sur-
gery as an elective procedure after a careful metabolic and
coagulation assessment and were classified according to
Child’s class9 and to the presence or absence of refractory
ascites. All patients with ascites were treated with increased
doses of diuretics up to 400 mg of spironolactone per day,
160 mg of furosemide per day, and sodium restriction (50
mEq/d). This medical management was continued until the
disappearance of ascites, and only at this point were the
patients operated on. A lack of body weight response, de-
fined as a loss of body weight less than 200 g/d after 4 days,
or the development of diuretic-induced complications that
precluded the use of effective diuretic dosage were defined
as refractory ascites.10 No patient received transjugular in-
trahepatic portosystemic shunt or peritoneovenous shunt
before enrollment and during the study period.
All hernioplasties were performed by 1 surgeon (GDV)
after short-term antibiotic prophylaxis with 2 g intravenous
ceftazidime 1 hour before surgery. In 8 patients, hernio-
plasty was performed under local anesthesia using a mixture
of 40 mL 1% mepivacaine and 20 mL 0.5% bupivacaine
plus 2 mL sodium bicarbonate. The remaining 24 were
treated under general anesthesia using thiopental sodium for
induction, vecuronium for neuromuscular blockade, isoflu-
rane and fentanyl citrate for analgesia. All patients received
a tension-free Lichtenstein hernioplasty using a polypro-
pylene mesh. The hernial sac was carefully isolated from the
related structures in order to avoid perforation, and, subse-
quently, it was invaginated without opening the abdominal
cavity. In patients with a large-size hernial sac, it was
cautiously isolated from the close structures. It was subse-
quently fastened on the basis, and its distal part was cut and
secured with a transfix suture to avoid the risk of ascitic leak
and, finally, invaginated at the internal inguinal ring. The
aponeurosis was closed performing water tight closure with
a running suture using a nonabsorbable monofilament. A
tubular suction drainage was placed in the dead space only
when it was large and in all patients with refractory ascites.
Patients were classified according to the presence or ab-
sence of refractory ascites and Child’s class.9
QOL assessment
The SF-36 is a widely used and validated scale that
yields scores for 8 dimensions of health-related QOL:
(1) physical functioning (PF): limitations to physical activ-
ities due to health, such as self care, walking, and climbing
stairs; (2) role physical (RP): interference with work or
daily activities due to physical health; (3) general health
(GH): overall evaluation of health; (4) bodily pain (BP):
pain intensity and how this pain affects work in and out of
the home; (5) vitality (VT): how full of energy the patient
feels; (6) mental health (MH): overall emotional and psy-
R. Patti et al. Inguinal hernioplasty
Table 1 Demographic data of 32 patients with cirrhosis
and SIH
Age (y)
Mean ⫾ SD 53.4 ⫾ 10.5
Sex
Female 0
Male 32
Etiology of liver cirrhosis
HCV 17
HBV 4
Alcoholic 9 Demographic data (age, sex, etiology of cirrhosis,
Cryptogenic 2
Child’s class
A 10
B 14
C 8
Refractory ascites
Present 10
Absent 22
HCV ⫽ hepatitis C virus; HBV ⫽ hepatitis B virus.
chologic status; (7) social functioning (SF): how much
health interferes with social interactions; and (8) role emo-
tional (RE): limitations to work or daily activities due to
emotional health.
The scores for each domain range from 0 to 100, 0 being
the poorest and 100 the best possible health status. How-
ever, 0 is not equivalent to death, and 100 is not equivalent
to perfect health. Two comprehensive indexes of QOL were
also evaluated: the Physical Component Summary (PCS),
which equals the value of the physical subscale (PF, RP,
GH, and BP), and the Mental Component Summary (MCS),
which equals the value of the psychosocial subscale (VT,
MH, SF, and RE).11,12
We used an Italian adaptation of the SF-36 generic
health–related QOL scale.7,8 The SF-36 questionnaire was
administered after a careful explanation by a trained physi-
cian (BS) to all patients the day before surgery. An identical
follow-up questionnaire was presented to the patients at a
follow-up visit 6 months after hernioplasty.
Global analysis of all patients was made through PCS,
MCS, and the evaluation of each of the 8 domains, whereas
only PCS and MCS were used to analyze the patients
according to their allocation related to the presence or ab-
sence of refractory ascites and to Child’s class.
Statistics
All statistical analyses were done using a statistical pro-
gram (GraphPad Instat Version 3.06 for Windows, San
Diego, CA USA). Continuous variables were summarized
by mean and standard deviation or median, categoric ones
by frequencies. Data from each domain of SF-36 were
analyzed by using nonparametric tests. The Mann-Whitney
U test was used to compare preoperative and postoperative
scores for each domain of SF-36. The 2 comprehensive
375
indexes of SF-36, PCS and MCS, were obtained by the sum
of the physical (PF, RP, GH, and BP) and the psychosocial
(VT, MH, SF, and RE) subscale and analyzed by the same
statistical test. Any P value ⬍.05 was considered signifi-
cant.
Results
Child’s class, and status of ascites) are shown in Table 1.
The type of hernia, according to Nhyus classification13; the
side of hernia; duration of operation; and duration of hos-
pital stay are reported in Table 2.
No significant complications were observed in any of
these patients during surgery. After surgery, ascites leakage
from the surgical wound or wound infection was never
observed. The wound drainage, placed in 18 patients, was
removed between 24 and 48 hours after surgery. During the
postoperative in-hospital time, 2 inguinoscrotal hematomas
appeared, both in a class B patient without ascites. A suction
drainage was not placed in any patient. Therefore, both
resolved spontaneously over the next week, with no need for
blood transfusions or reintervention. Six months after her-
nioplasty, all patients were alive, no hernia recurrence was
detected, and liver disease was stable in all subjects.
The assessment of QOL
The subjects, actively involved in the study protocol,
showed a high level of satisfaction and a good compliance
to SF-36. In fact, all of them completed their questionnaire
both preoperatively and 6 months after surgery. All 8 do-
mains of SF-36 improved significantly during the postop-
erative time (Fig. 2). This enhancement was more evident
for BP, RP, SF, and GH (Fig. 2). Postoperative MCS and
PCS scores significantly increased as compared with basal
values (Fig. 3A and B).
Table 2 Classification of inguinal hernia and description of
surgical features of 32 patients with cirrhosis and SIH
Type of hernia (Nyhus)
II 2
III A 14
III B 13
IV A 3
Side of hernia
Right 16
Left 12
Bilateral 4
Duration of operation (min)
Mean ⫾ SD 50.1 ⫾ 14.0
Hospital stay (d)
Mean ⫾ SD 2.9 ⫾ 1.5
SD ⫽ standard deviation.
376
Figure 2 Comparison between preoperative and postoperative
score of each domain of SF-36. Data are expressed as median.
White square ⫽ preoperative time; black square ⫽ postoperative
assessment. A Mann-Whitney U test was used to compare preop-
erative and postoperative values.
The improvement of PCS was more important in patients
with refractory ascites with respect to those with treatable
ascites (Fig. 4A); in fact, the rate of increase of the PCS
score was 40.2% versus 17.7%, respectively. Even more
Figure 3 Preoperative and postoperative score for (A) MCS and
(B) PCS. Values are expressed as median and range. Error bars
inside the box expressed the minimum and maximum value
(range), and the continuous line inside the box expressed the
median. A Mann-Whitney U test was used to analyze preoperative
and postoperative data.
The American Journal of Surgery, Vol 196, No 3, September 2008
Figure 4 Preoperative (white box) and postoperative (pointed
box) score for (A) PCS and (B) MCS in patients with and without
refractory ascites. Error bars inside the box expressed the mini-
mum and maximum value (range), and the continuous line inside
the box expressed the median. A Mann-Whitney U test was used
to analyze preoperative and postoperative data.
remarkable results were observed in MCS where the respec-
tive increase was 61.1% and 6.8% (Fig. 4B).
The values of MCS were increased with respect to those
detected in the preoperative assessment in all Child’s
classes. Specifically, this change was more relevant in pa-
tients in class C with an increase of 61.3% between the
preoperative and postoperative scores. Actually, the differ-
ence among pre- and postoperative values was significant
also in patients of class A and B (Fig. 5A). The postoper-
ative scores for PCS were remarkably higher as compared
with those detected in preoperative time in all Child’s
classes, even though in patients of class C the rate of
increase was 45.5% and the results more apparent as com-
pared with other classes (Fig. 5B).
Comments
The optimal management of IH in patients with cirrhosis
with or without ascites remains a matter of debate. Pere et al14
R. Patti et al. Inguinal hernioplasty
Figure 5 Preoperative (white box) and postoperative (pointed
box) score for (A) MCS and (B) PCS in patients of different
Child’s classes. Errors bars inside the box expressed the minimum
and maximum value (range), and the continuous line inside the box
expressed the median. A Mann-Whitney U test was used to ana-
lyze preoperative and postoperative data.
reported on 3 patients with stable cirrhosis and controlled
ascites whose conditions severely deteriorated after elective
inguinal herniorrhaphy. A Danish nationwide cohort study
showed that among 256 patients with cirrhosis undergoing
IH repair 7 died within 30 days compared with 5 of 74 in the
control group, resulting in an adjusted odd ratio for 30-day
mortality of 4.4.15 Others studies based on treatment expe-
rience of hernias of the abdominal wall (umbilical, inguinal,
and incisional) have suggested that in patients with decom-
pensated cirrhosis these hernias may be safely repaired on
elective basis,16 without an increased surgical risk or an
undue incidence of recurrences.6
Patients in our study underwent elective hernia repair
after an extensive clinical assessment and intensive man-
agement of ascites. This allowed us to show that a tension-
free hernioplasty for SIH is associated with a low rate of
problems even when performed in patients with advanced,
decompensated cirrhosis. The short time to recovery and the
improved objective and subjective states of health go along
with an improved QOL at 6 months of follow-up. The
377
specific SF-36 analysis, obtained comparing preoperative
and postoperative data, was assessed as a paired dataset of
the same patient17 and analyzed using nonparametric
tests.18 This approach has revealed an overall improvement
of each domain of SF-36, this being more relevant for BP,
RP, SF, and GH. The overall analysis of MCS and PCS
showed that both parameters improved more markedly in
patients with ascites and advanced liver disease (ie, those in
whom the negative effects of SIH are more likely to occur).
Over the last 15 years, there has been an increasing
consensus regarding the centrality of the patient’s point of
view in the assessment of health status. In fact, the percep-
tion of one’s own health status may be more relevant than
prolonging length of life because patients are frequently
more concerned about quality and disability than longevity.19
Both IH and cirrhosis are responsible for the impairment of
QOL. Mathur et al20 using cross-sectional psychometric anal-
ysis have shown that otherwise healthy subjects with IH have
a significantly lower QOL compared with age-, sex-, and
comorbidity-matched controls. In all 8 domains of the SF-36
score, patients achieved lower scores than controls, including
an impaired QOL in terms of their vitality, social functioning,
mental health, and overall perceptions of general health.
Hernioplasty itself is able to improve QOL. O’Dwyer et
al’s trial surgery5 has been compared with a “wait and see”
policy in patients with asymptomatic hernia. They found
that, after 6 months, there was a significant improvement in
most dimensions of the SF-36 in the operation group,
whereas after 12 months, although the trend remained the
same, the differences were only significant for change in the
general health domain.
Lawrence et al21 in a randomized controlled trial of
patients undergoing IH repair have observed a significant
improvement of QOL, assessed using SF-36, between pre-
operative and postoperative score. In particular, this im-
provement was much higher for the domains of pain and
physical function.21 Zieren et al22 in their study, using the
SF-36 to compare preoperative and postoperative QOL in
patients undergoing “plug and patch” hernia repair, showed
a significant postoperative overall improvement of QOL in
all domains of SF-36. In a large prospective randomized
trial,23 it has been shown that in both open and laparoscopic
herniorrhaphy there was an improvement in MCS and PCS
scores at 2 years; also, a hernia recurrence did not affect a
patient’s postoperative health status, whereas neuralgia or
orchitis resulted in a decrease in overall health status com-
pared with patients without those complications.24
On the other hand, QOL is variably impaired in cirrhosis.
Marchesini et al25 measured QOL by SF-36 questionnaires
in patients with cirrhosis, and all domains scored signifi-
cantly lower in comparison to a matched healthy Italian
population. The largest differences were observed in the
role limitation physical, general health, and role limitation
emotional, whereas bodily pain was minimally affected.25
Also, the severity of disease, evaluated by Child’s score,
378 The American Journal of Surgery, Vol 196, No 3, September 2008
was the factor most closely associated with poor health
status perception.25
In conclusion, we showed that tension-free inguinal
hernia repair in cirrhotic patients can be safely done with
a low rate of complications. The improvement of QOL,
especially in patients with symptomatic hernia and ad-
vanced liver disease, could represent a clear indication
for elective hernia repair.
References
1. Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrho-
sis. Semin Liver Dis 1997;17:219 –26.
2. Mansour A, Watson W, Shayani V, et al. Abdominal operations in
patients with cirrhosis: still a major surgical challenge. Surgery 1997;
122:730 –5.
3. Hurst RD, Butler BN, Soybel DI, et al. Management of groin hernias
in patients with ascites. Ann Surg 1992;216:696 –700.
4. Hair A, Duffy K, McLean J, et al. Groin hernia repair in Scotland. Br J
Surg 2000;87:1722– 6.
5. O’Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for
patients with an asymptomatic inguinal hernia: a randomized clinical
trial. Ann Surg 2006;244:167–73.
6. Park JK, Lee SH, Yoon WJ, et al. Evaluation of hernia repair operation
in Child-Turcotte-Pugh class C cirrhosis and refractory ascites. J
Gastroenterol Hepatol 2007;22:377– 82.
7. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health
survey [SF-36]. I. Conceptual framework and item selection. Med
Care 1992;30:473– 83.
8. Apolone G, Mosconi P. The Italian SF-36 Health Survey: translation,
validation and norming. J Clin Epidemiol 1998;51:1025–36.
9. Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG,
editor. The Liver and Portal Hypertension. Philadelphia: Saunders;
1964:50.
10. Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria
of refractory ascites and hepatorenal sindrome in cirrhosis. Interna-
tional Ascites Club. Hepatology 1996;23:164 –76.
11. Hays RD, Marshall GN, Wang EYI. Four-year cross-lagged associa-
tions between physical and mental health in medical outcome study. J
Consult Clin Psychol 1994;62:441–9.
12. Rumsfeld JS, Magid DJ, O’Brien M, et al. Changes in health-related
quality of life following coronary artery bypass graft surgery. Ann
Thorac Surg 2001;72:2026 –32.
13. Nyhus LM. Individualisation of hernia repair: a new era. Surgery
1993;114:1–2.
14. Pere P, Hockerstedt K, Lindgren L. Life-threatening liver failure after
inguinal herniorrhaphy in patients with cirrhosis. Eur J Surg 1999;165:
1000 –2.
15. Hansen JB, Thulstrup AM, Vilstup H, et al. Danish nationwide cohort
study of postoperative death in patients with liver cirrhosis undergoing
hernia repair. Br J Surg 2002;89:805– 6.
16. Ozden I, Emre A, Bilge O, et al. Elective repair of abdominal wall
hernias in decompensated cirrhosis. Hepatogastroenterology 1998;45:
1516 – 8.
17. Hamming JF, De Vries J. Measuring quality of life. Br J Surg 2007;
94:923– 4.
18. Velanovich V. Behavior and analysis of 36-item Short-Form Health
Survey data for surgical quality-of-life research. Arch Surg 2007;142:
473–7.
19. McNeil BJ, Weichselbaum R, Pauker SG. Speech and survival:
tradeoffs between quality and quantity of life in laryngeal cancer.
N Engl J Med 1981 22;305:982–7.
20. Mathur S, Bartlett AS, Gilkison W, et al. Quality of life assessment in
patients with inguinal hernia. ANZ J Surg 2006;76:491–3.
21. Lawrence K, McWhinnie D, Jenkinson C, et al. Quality of life in
patients undergoing inguinal hernia repair. Ann R Coll Surg Engl
1997;79:40 –5.
22. Zieren J, Kupper F, Paul M, et al. Inguinal hernia: obligatory indica-
tion for elective surgery? A prospective assessment of quality of life
before and after plug and patch inguinal hernia repair. Langenbecks
Arch Surg 2003;387:417–20.
23. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus
laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:
1819 –27.
24. Hawn MT, Itani KM, Giobbie-Hurder A, et al. Patient-reported out-
comes after inguinal herniorrhaphy. Surgery 2006;140:198 –205.
25. Marchesini G, Bianchi G, Amodio P, et al. Italian Study Group for quality
of life in cirrhosis. Factors associated with poor health-related quality of
life of patients with cirrhosis. Gastroenterology 2001;120:170 – 8.