When a hernia is not a hernia: The evaluation of inguinal hernias in the cirrhotic patient

Herniorrhapy in patients with advanced portal hypertension and ascites should be approached with caution, and treated conservatively whenever possible. Cirrhosis increases the risk of significant perioperative complications such as infection, recurrence, and ascites leak. This paper reports two patients operated on for suspected inguinal hernias. The first patient was referred for elective repair of a presumed inguinal hernia before liver transplantation. The second patient presented with a history of an incarcerated inguinal hernia that was previously reduced in the emergency center. After examination by residents and senior faculty the patients were scheduled for elective herniorrhaphy. Intraoperatively no inguinal hernia could be identified in either patient. However, massively dilated veins (1.5-2.0 cm in diameter) were noted entering with the spermatic cord at the internal inguinal ring. In both cases the veins were clamped, transected, and suture ligated at the internal ring. Given the unusual presentation of these dilated veins in both patients we advocate the use of preoperative Doppler ultrasound in patients with cirrhosis and suspected inguinal hernias.