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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 522-527

Feasibility of local anesthesia for treatment of uncomplicated umbilical hernia in patients with ascitic cirrhosis


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Damanhour Medical National Institute, Damanhour, El Beheira, Egypt

Date of Submission12-Dec-2017
Date of Acceptance20-Jan-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Mohamed M Zeater
Department of Surgery, Damanhour Medical National Institute, Damanhour 22516, El Beheira
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_834_17

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  Abstract 


Objective
The aim of this study was to evaluate the effectiveness of local anesthesia in umbilical herniorrhaphy in patients having cirrhosis with controlled ascites.
Background
Umbilical hernia is a common abdominal wall complication of liver cirrhosis. The prevalence of umbilical hernia in patients having cirrhosis with ascites is up to 20%. Local anesthesia often provides maximum comfort for patients when it is accurately performed in open repairs. However, convincing evidence is lacking.
Patients and methods
This prospective study was carried out on 40 patients at Menoufia University Hospital and Damanhour Medical National Institute during the period from June 2016 till October 2017. All patients with cirrhosis with controlled ascites and uncomplicated umbilical hernia were included in this study. Exclusion criteria were complicated hernia, huge hernia, and local anesthesia hypersensitivity. All patients underwent elective umbilical herniorrhaphy under local anesthesia. Patients were followed up for 1 year. The complications and the outcome of the operation were recorded.
Results
Overall, 87.5% of patients passed without any complications, and 2.5% of them converted from local anesthesia to general anesthesia owing to omental injury (one patient). We inserted a surgical drain in 10% of patients. Most of patients (92.5%) were satisfied by this technique with different degrees of satisfaction, with 2.5% recurrence rate.
Conclusion
Umbilical herniorrhaphy under local anesthesia in patients with cirrhosis is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity.

Keywords: ascites, herniorrhaphy, liver cirrhosis, local anesthesia, recurrence


How to cite this article:
Albatanony AA, El Balshy MA, Zeater MM. Feasibility of local anesthesia for treatment of uncomplicated umbilical hernia in patients with ascitic cirrhosis. Menoufia Med J 2019;32:522-7

How to cite this URL:
Albatanony AA, El Balshy MA, Zeater MM. Feasibility of local anesthesia for treatment of uncomplicated umbilical hernia in patients with ascitic cirrhosis. Menoufia Med J [serial online] 2019 [cited 2019 Sep 21];32:522-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/522/260930




  Introduction Top


Cirrhosis represents the final stage of all chronic liver diseases[1].

Hepatitis B virus infection, hepatitis C virus infection, and alcohol consumption are considered to be the major global etiologies of liver cirrhosis[2].

The prevalence of umbilical hernia in the adult population is 2%[3], whereas in patients with cirrhosis with ascites is up to 20%[4].

Complications of these hernias can be serious, and mortality rates as high as 30% have been reported. Skin ulceration and subsequent rupture of the hernia sac and leakage are common, which can result in bacterial peritonitis and serious morbidity[2],[5].

The indications for umbilical herniorrhaphy in patients with cirrhosis, unfortunately, remains controversial, as there are no high-quality prospective studies to address this question[6].

Elective umbilical herniorrhaphy among patients with cirrhosis is the standard treatment nowadays[5].

Effective ascites management is essential to achieve umbilical hernia repair success as well as to reduce recurrence rate[7].

Local anesthesia can be used safely in umbilical and paraumbilical hernia repairs. However, the number of detailed reports on the repair of these hernias by using local anesthesia is limited. The data usually lack information about the technique and doses of local anesthesia applied[8],[9].

The aim of this study was to evaluate the effectiveness of local anesthesia in umbilical herniorrhaphy in patients with cirrhosis with controlled ascites.


  Patients and Methods Top


This prospective study was done on a consecutive sample of 40 patients who were admitted to Menoufia University Hospital and Damanhour Medical National Institute and satisfied the inclusion and exclusion criteria to be enrolled in the study during the period from June 2016 till October 2017.

Ethical issue

The procedure followed in the study was in accordance with the ethical committee of Menoufia Faculty of Medicine and Damanhur Medical National Institute, and written consents were taken from the patients or their guardians.

Inclusion criteria

Patients with cirrhosis with controlled ascites and uncomplicated umbilical hernia were included in the study.

Exclusion criteria

The study excluded any complicated hernia such as strangulated, obstructed, inflammed or recurrent hernia also huge hernia was excluded due to its need for more than toxic dose to be anesthetized. Furthermore the study excluded any patient who had local anesthesia hypersensitivity.

All patients were subjected preoperatively to the following: detailed history taking and clinical examination. Their last investigations were revised from their files in the records.

The impaired hepatic patients were prepared preoperatively in cooperation with internal medicine, tropical, biochemistry, and radiological staff for approximately 3–4 weeks.

Preoperative initial management to control ascites consists of education of the patient about limiting dietary sodium to 80–120 mmol daily and oral diuretic treatment. Diuretic therapy should start with a morning dose of spironolactone 100 mg with or without furosemide 40 mg. Renal function and serum electrolyte concentrations should be monitored during diuretic treatment, particularly when doses are being gradually increased to achieve adequate weight loss, which should not exceed 1 kg/day in patients with peripheral edema or 0.5 kg/day in those without.

Patients were advised to use alcohol 70% solution to clean the umbilicus twice on the day before the operation topically. The umbilicus was also cleaned by the surgeon meticulously before incision.

Elective umbilical herniorrhaphy was performed with the patient in the supine position under local anesthesia. All patients received an appropriate single dose of a prophylactic antibiotic (third generation cephalosporin) before skin incision.

Local infiltration of anesthesia in the operative field was done in the manner of layer by layer by layer (intradermal, subdermal, and subcutaneous) along the line of skin incision that had been marked previously, and administration of local anesthesia using lidocaine 1% (equal to 20 mg/ml in a 50-ml bottle with a dose of 4 mg/kg) as a maximum dose. The amount of the local anesthesia was adjusted according to the size of the umbilical hernia, which had been diluted with normal saline in a ratio 1:1 and injected by a 10-ml disposable plastic syringe of needle size 21 G and length 1.5 inch (38 mm) with green color code that should be grasped between the index and middle finger above and the thumb pressing on its injector and the needle facing forward forming a 45° with the skin surface with its bevel directed upward.

Then a curvilinear transverse incision is made in a natural skin crease and should not exceed 180°. Additionally, an elliptical incision can be used for large hernias that require excision of excess skin or distorted umbilicus and holding the skin edges either side using Littlewoods or Allis clamps.

Thereafter, incisioning was done through the subcutaneous fat to the rectus sheath with a fine-tipped instrument and electrocautery, and abundant skin overlying the hernia is excised to clear fat from the hernia sac and to clear the abdominal wall circumferentially from the edges of the defect. If needed, another dose of local anesthesia can be used to infiltrate the aponeurosis of both recti (anterior rectus sheath).

Meticulous dissection should be considered not to enter the hernial sac, and the contents of the hernial sac are reduced. If the contents are not adherent, the neck of hernial sac is transfixed, and the sac is excised. If the contents of the hernia sac are adherent to the sac, the sac is opened and adhesions are freed. The contents are inspected for viability, and any compromised adherent omentum is resected.

Then the peritoneum is closed with an absorbable running suture. Flaps of fascia are closed using Mayo's technique by nonabsorbable sutures.

The undersurface of the umbilicus is fixed to the fascia in case of umbilical preservation. If large skin flaps have been raised, the subcutaneous space can be closed with absorbable suture with or without tubal drain.

The wound is then closed with a running subcuticular or interrupted suture.

Postoperative follow-up

Early postoperative complications, for example, wound infection, seroma, hematoma, postoperative ileus, and peritonitis if any, were recorded and taken care of. Patients were discharged after sufficient pain relief was achieved. Patients were asked to follow-up monthly for 1 year. The wide range of follow-up period was determined for detection of later complications, mainly hernia recurrence.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 for windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software BVBA, Ostend, Belgium). Qualitative data were described using numbers and percentages. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, and median.


  Results Top


The age of patients ranged between 40 and 70 years, with a mean age of 52.35 ± 7.73 years. Twenty-eight (70%) cases were males whereas 12 (30%) cases were females, with a male to female ratio of 2.3:1 [Table 1].
Table 1: Demographic data of the studied group

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The dose of local anesthetic agent was calculated according to patient's weight and toxic dose (4 mg/kg). The amount of anesthetic agent that was admitted ranged between 20 and 40 ml diluted lidocaine 1% with normal saline in a ratio 1:1, which was used in the procedure with a mean value of 32.58 ± 5.57 ml.

Thirty-six (90%) patients were compliant with this type of anesthesia 'local, regional' whereas only four (10%) patients were noncompliant and needed more amount of anesthesia up to 50 ml to be completely anesthetized [Figure 1].
Figure 1: Compliance of patients of the study.

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We used the visual analog score (VAS) for assessing the degree of pain felt by patients during the procedure of the operation. The pain score ranged between 1 and 9, with a mean value of 3.81 ± 2.57. When we classified patients according to pain score, we found that 31 (77.5%) patients had mild to moderate pain, with score ranging from 1 to 7, with a mean value of 2.497 ± 0.0422, whereas nine (22.5%) patients had severe pain, with score ranging between 7 and 9, with a mean value of 8.33 ± 0.71. Those patients were treated by intravenous paracetamol (1000 mg every 8 h).

The statistical analysis revealed that most patients had mild to moderate pain score [Table 2].
Table 2: Pain score in patients of our study

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The operative time ranged between 20 and 45 min, with a mean value of 32.7 ± 6.7 min.

A total of 35 (87.5%) patients passed smoothly without any intraoperative complications, whereas five (12.5%) cases had intraoperative and postoperative complications: one (2.5%) of them had intraoperative omental injury, two (5%) of them had severe wound infection, one (2.5%) had hematoma, and one (2.5%) case had ascitic leak [Figure 2].
Figure 2: Complications in our groups.

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One of our patients (2.5%) was converted from local anesthesia to general anesthesia, which was mainly because of intraoperative complication (omental injury), whereas 39 (97.5%) patients completed under local anesthesia [Table 3].
Table 3: Conversion rate and postoperative drain in patients of our study

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In our patients, we inserted a surgical drain in the wound in four (10%) patients whereas 36 (90%) patients passed without putting a surgical drain [Table 3].

The period of drain in the wound ranged between 3 and 7 days with a mean period of 4.6 ± 1.5 days [Table 3].

Most patients of our study (92.5%) were satisfied by our technique but in different degrees, and the satisfaction ranged between 75 and 100%, with a mean value of satisfaction of 88.38 ± 7.88%. Patient satisfaction upon our technique was evaluated through answering a question 'would you recommend this operation to other patients?'.

During the early postoperative period, four (10%) of our patients had complications: two (5%) cases of severe skin infection, one (2.5%) ascitic fluid leak from the wound, and one (2.5%) postoperative hematoma [Table 4].
Table 4: Rate of postoperative complications in patients of our study

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During the follow-up period of 1 year, we had one (2.5%) case of recurrence after 9 months of follow-up owing to ascitic fluid leak and partial wound dehiscence, whereas the other patients had been treated conservatively [Table 4].


  Discussion Top


Umbilical hernia is a common abdominal wall complication of liver cirrhosis[10]. Patients with liver cirrhosis and ascites exhibit peritoneal distension and frequently have subsequent herniation of the weakest structures in the abdominal wall[11].

Indeed, umbilical hernias, which occur in 3% of the population in general, are present in 20% of patients with cirrhosis and ascites[12].

Traditionally, the surgical treatment of umbilical hernia in those patients was avoided because of a significant recurrence rate and postoperative morbidity/mortality. However, conservative treatment is also associated with high mortality rates because of the strong likelihood of emergency situations, such as incarcerated hernias or rupture of the hernia sac[4].

Several factors such as increased abdominal tension owing to the presence of tense ascites, malnutrition, and worsening muscle wasting are major risk factors for the development of abdominal hernias in these patients. Moreover, owing to the presence of increased surgical risk factors in patients with cirrhosis, high perioperative morbidity and mortality are often encountered[13].

The indication for surgical repair of abdominal wall hernias in patients with cirrhosis remains a controversial issue. No high-quality, prospective studies have been performed to address this important question. The delay in hernia surgery is also directly related to an increased risk of life-threatening complications requiring emergency repair[14].

In summary, it seems that the elective repair of uncomplicated umbilical hernias is safe in selected patients and that past reports of prohibitive morbidity and mortality are too high compared with the current results. The risks of delayed repair on an urgent basis when complications arise may be higher than the risks of early prophylactic repair. Unfortunately, proper selection criteria are lacking, and surgeons must use clinical judgment, and although improving mortality and morbidity rates have prompted many to propose early repair, it appears that, with increasing Child's classification, many are still reluctant to do this[5].

The data usually lack information about the technique and doses of local anesthesia applied. Therefore, we aimed to report an analysis of umbilical hernia repair in patients with cirrhosis under local anesthesia.

The local anesthesia technique has a learning curve that requires specific training[8]. However, fears about the safety of administering large doses of lidocaine or bupivacaine into umbilical region have been exaggerated. Kastrissios et al.[15] demonstrated that peak venous plasma bupivacaine level at 15 min to 2 h was 0.07–1.4 ml/l, which is well below the cardiovascular toxicity level (4 mg/l) and central nervous system toxicity level (1.1–2.4 mg/l).

Following doses approaching the recommended maximum for infiltration of lidocaine (7 mg/kg), Karatassas et al.[16] demonstrated that peak lidocaine concentration ranged between 0.23 and 0.9 mg/l, with the toxicity threshold being 5 mg/l. There is a wide safety margin for the use of either bupivacaine or lidocaine for the currently recommended doses, with 4 and 7 mg/kg, respectively.

In our study, the age of patients ranged between 40 and 70 years, with a mean age of 52.35 ± 7.73 years. There was a male predominance, as 70% of cases were males and 30% were females.

This is similar to Wang et al.[10] who studied 157 patients with umbilical hernia with cirrhosis and found that the mean age of their patients was 59.11 ± 11.98 years, with a male predominance of 63.1%.

Andraus et al.[14] showed that the mean age of their patients ranged between 45 and 60 years, with a mean age of 51 years, with 87% of their patients being males.

In this study, we used local 'regional' anesthesia for patients, and the mean amount of local anesthetic agent (diluted lidocaine 1%) used was 32.58 ± 5.57 ml, with compliance in 90% of cases for this type of anesthesia.

This is similar to Kulacoglu et al.[17] in their study on repair of umbilical hernia in patients with cirrhosis, as they found that the mean amount of the local anesthetic diluted lidocaine 1% was 33 ml (10–63 ml).

In this study, the mean operative time was 32.7 ± 6.7 min, and this is similar to six authors who investigated the duration of surgery, which ranged from 24 to 58 min[17].

In our study, we used the VAS for assessing the degree of pain felt be patients during the procedure of the operation, and it showed that most patients had mild to moderate pain score, with a minority of cases having severe score.

Five studies reported on patient satisfaction, which was reported to be good in 89 to 97% of patients. Different methods of measuring this outcome parameter were used. Acevedo and Leon[18] defined patient satisfaction as good, if the VAS for patient satisfaction was below seven points on a 10-point scale, in combination with a positive answer to the question 'would you recommend this kind of surgery to others?'.

This is also similar to Sinha and Keith[19] who stated that 97% of patients were satisfied.

Kulacoglu et al.[17], Bennett et al.[20], and Dalenbäck et al.[21] did not describe which questionnaire was used to define and measure patient satisfaction.

Acevedo and Leon[18] specified the patient satisfaction regarding postoperative nausea and vomiting in patient.

Patients with cirrhosis have higher incidences of abdominal wall complications. Moreover, the presence of abdominal hernias has a major effect on quality of life in this patient population[14],[22].

Farooqe Dar et al.[11] in their study found that the early postoperative complications was 16.1%, as 2.9% had wound infection, 8.8% had wound seroma, and 4.4% had wound hematoma, and this was in agreement with our results.

Yu et al.[4] in their study found 22% recurrence rate, which is much more than the recurrence rate in our study; 17% developed seroma at the surgical sites and 5% experienced hepatic coma, and this was also in agreement with our study. They denoted that uncontrollable ascites was responsible for the recurrences.

McKay et al.[5] documented in their study that the relative risk of recurrence in umbilical hernia was 8.51% which was in agreement with our results and referred the reduction in postoperative complications and related deaths to the improvements in perioperative patient care and recent developments in surgical techniques.

This is also similar to Hassan et al.[23], who in their study of 70 cases of umbilical hernias with liver cirrhosis found 10% complication rate in the form of wound infection (2.9%), wound seroma (4.3%), ascitic fistula (1.4%), hernia recurrence (1.4%), and ICU admission (4.3%).

Limitations

In spite of patient showing distress during local anesthesia, this was the best available anesthesia technique for those patients, owing to high mortality rate and complications of general anesthesia. The high rate of patient satisfaction with this technique which was explored through their recommendation of this procedure for other patients may clarify that their suffering during the procedure was accepted when compared with the risks of general anesthesia.

Although rectus sheath block is a preferable technique, it was not performed because our institute lacks well-experienced intervention radiologists regarding this technique and limitations in the equipment.

Recommendation

Further studies with using sonar-guided rectus sheath block should be performed to decrease patient suffering and improve patient satisfaction, as this is the era of intervention radiology.


  Conclusion Top


Local anesthesia for treatment of umbilical hernia in patients with cirrhosis is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity. Conversion to general anesthesia should be considered when it is difficult or dangerous to continue with local anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: evidence based treatment. World J Gastroenterol 2014; 20:5442–5460.  Back to cited text no. 1
    
2.
Yao J, Chang L, Yuan L, Duan Z. Nutrition status and small intestinal bacterial overgrowth in patients with virus-related cirrhosis. Asia Pac J Clin Nutr 2016; 25:283–291.  Back to cited text no. 2
    
3.
García-Ureña MA, García MV, Ruíz VV, Carnero FJ, Huerta DP, Jiménez MS. Anesthesia and surgical repair of aponeurotic hernias in ambulatory surgery. Ambul Surg 2000; 8:175–178.  Back to cited text no. 3
    
4.
Yu BC, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. Ann Surg Treat Res 2015; 89:87–91.  Back to cited text no. 4
    
5.
McKay A, Dixon E, Bathe O, Sutherland F. Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia 2009; 13:461–468.  Back to cited text no. 5
    
6.
Cassie S, Okrainec A, Saleh F, Quereshy FS, Jackson TD. Laparoscopic versus open elective repair of primary umbilical hernias: short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program. Surg Endosc 2014; 28:741–746.  Back to cited text no. 6
    
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Kingsnorth A. Local anesthetic hernia repair: gold standard for one and all. World J Surg 2009; 33:142–144.  Back to cited text no. 8
    
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Wang R, Qi X, Peng Y, Deng H, Li J, Ning Z, et al. Association of umbilical hernia with volume of ascites in liver cirrhosis: a retrospective observational study. J Evid Base Med 2016; 9:170–180.  Back to cited text no. 10
    
11.
Farooq Dar M, Butt MQ, Sheen SN, Tariq Z, Ghani UF, Qadir I. Hernia repair in patients with chronic liver disease. Pak Armed Forces Med J 2016; 66:395–399.  Back to cited text no. 11
    
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Ecker BL, Bartlett EK, Hoffman RL, Karakousis GC, Roses RE, Morris JB, et al. Hernia repair in the presence of ascites. J Surg Res 2014; 190:471–477.  Back to cited text no. 12
    
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Arif R, Seppelt P, Schwill S, Kojic D, Ghodsizad A, Ruhparwar A, et al. Predictive risk factors for patients with cirrhosis undergoing heart surgery. Ann Thorac Surg 2012; 94:1947–1952.  Back to cited text no. 13
    
14.
Andraus W, Soares R, Pinheiro1 Q. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg 2015; 15:65–71.  Back to cited text no. 14
    
15.
Kastrissios H, Triggs EJ, Sinclair F, Moran P, Smithers M. Plasma concentrations of bupivacaine after wound infiltration of a 0.5% solution after inguinal herniorrhaphy: a preliminary study. Eur J Clin Pharmacol 1993; 44:555–557.  Back to cited text no. 15
    
16.
Karatassas A, Morris RG, Walsh D, Hung P, Slavotinek AH. Evaluation of the safety of inguinal hernia repair in the elderly using lignocaine infiltration anaesthesia. Aust NZ J Surg 1993; 63:266–269.  Back to cited text no. 16
    
17.
Kulacoglu H, Yazicioglu D, Ozyaylali I. Prosthetic repair of umbilical hernias in adults with local anaesthesia in a day-case setting: a comprehensive report from a specialized hernia center. Hernia 2012; 16:163–170.  Back to cited text no. 17
    
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Acevedo A, Leon J. Ambulatory hernia surgery under local anaesthesia is feasible and safe in obese patients. Hernia 2010; 14:57–62.  Back to cited text no. 18
    
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Sinha SN, Keith T. Mesh plug repair for paraumbilical hernia. Surgeon 2004; 2:99–102.  Back to cited text no. 19
    
20.
Bennett PC, Kumar B, Coveney EC. Local anesthetic repair of uncomplicated paraumbilical hernia without sedation: peri-operative pain and patient satisfaction. Hernia 2013; 17:499–504.  Back to cited text no. 20
    
21.
Dalenbäck J, Andersson C, Ribokas D, Rimbäck G. Long-term follow-up after elective adult umbilical hernia repair: low recurrence rates also after non-mesh repairs. Hernia 2013; 17:493–497.  Back to cited text no. 21
    
22.
Belyansky I, Tsirline VB, Klima DA, Walters AL, Lincourt AE, Heniford TB. Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs. Ann Surg 2011; 254:705–714.  Back to cited text no. 22
    
23.
Hassan AMA, Salama AF, Hamdy H, El-Sebae MM, Abdelaziz AM, El-Zayat WA. Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites. Intl J Surg 2014; 12:181–185.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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