Spontaneous umbilical hernia rupture with omental evisceration and Flood syndrome


  • Rachel Colbran Department of General Surgery, Ipswich Hospital, Ipswich, Queensland, University of Queensland, Brisbane, Queensland http://orcid.org/0000-0002-8781-225X
  • Alison Smith Department of General Surgery, Ipswich Hospital, Ipswich, Queensland,
  • Aemelia Melloy Department of General Surgery, Ipswich Hospital, Ipswich, Queensland,
  • Ramesh Iyer Department of General Surgery, Ipswich Hospital, Ipswich, Queensland,




Hernia, Evisceration, Cirrhosis, Flood syndrome


Cirrhotic patients are at increased risk of developing umbilical hernias. Many cirrhotic patients’ umbilical hernias are not repaired electively due to concerns for high perioperative morbidity and mortality. This case report aims to inform clinicians about the unique challenges that arise during emergency management of umbilical hernias in the cirrhotic patient. A 59-year-old male with Child-Turcotte-Pugh grade B cirrhosis presented to our hospital with an incarcerated umbilical hernia that spontaneously ruptured with large volume ascitic leak (known as Flood syndrome) and omental evisceration. The patient underwent emergency sutured umbilical hernia repair, and required a prolonged post-operative stay in the hospital intensive care unit after suffering from complications including spontaneous bacterial peritonitis, anaphylaxis to antibiotic treatment, aspiration pneumonia, encephalopathy and worsening ascites. He eventually made a good recovery and underwent rehabilitation prior to discharge home. This case highlights the rare complication of spontaneous omental evisceration of an umbilical hernia in the cirrhotic patient and details its subsequent management. It is important to note that elective hernia repair after medical optimisation is high risk in the cirrhotic patient, but is recommended to avoid the high perioperative mortality and morbidity associated with emergency repair.


Salamone G, Licari L, Guercio G, Campanella S, Falco N, Scerrino G, et al. The abdominal wall hernia in cirrhotic patients: a historical challenge. World J Emerg Surg. 2018;13.

Odom S, Gupta A, Talmor D, Novack V, Sagy I, Evenson AR, et al. Emergency hernia repair in cirrhotic patients with ascites. J Trauma Acute Care Surg. 2013;75:404-9.

Nguyen E. Flood syndrome: spontaneous umbilical hernia rupture leaking ascitic fluid-a case report. Perm J. 2017;21:16-152.

Marsman H, Heisterkamp J, Halm JA, Tilanus HW, Metselaar HJ, Kazemier G. Management in patients with liver cirrhosis and an umbilical hernia. Surgery. 2007;142:372-5.

Im G, Lubezky N, Facciuto M, Schiano TD. Surgery in patients with portal hypertension. Clinics in Liver Dis. 2014;18:477-505.

Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730-5.

Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg. 2005;140:650-4.

Coelho J, Claus C, Campos A, Costa M, Blum C. Umbilical hernia in patients with liver cirrhosis: A surgical challenge. World J Gastrointest Surg 2016;8:476-482.

Carbonell A, Wolfe L, DeMaria E. Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia. 2005;9:353-7.

Chatzizacharias N, Bradley J, Harper S, Butler A, Jah A, Huguet E, et al. Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol. 2015;21:3109-13.

Buckley D, Pemberton P. Rupture (evisceration) of an umbilical hernia. Med J Aust. 1988;149:715.

Chatterjee S. Spontaneous rupture of umbilical hernia with evisceration of small intestine. J Indian Med Assoc. 1972;59:287.

Choo E, McElroy S. Spontaneous bowel evisceration in a patient with alcoholic cirrhosis and an umbilical hernia. J Emerg Med. 2008;34:41-3.

Ginsburg B, Sharma A. Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med 2006;30:155-7.

Ogu U, Valko J, Wilhelm J, Dy V. Spontaneous evisceration of bowel through an umbilical hernia in a patient with refractory ascites. J Surg Case Rep. 2013;2013(10):rjt073.

Stein I, Straus F. A case of spontaneous evisceration through an umbilical hernia. Ill Med J.1951;99:147-9.

Telem D, Schiano T, Divino C. Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: management and outcome. Surgery. 2010;148:538-43.

Chul Yu B, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. ASTR. 2015;89:87-91.

Cho S, Bhayani N, Newell P, Cassera MA, Hammill CW, Wolf RF, et al. Umbilical hernia repair in patients with signs of portal hypertension: surgical outcome and predictors of mortality. Arch Surg. 2012;147:864-9.

Andraus W, Pinheiro R, Lai Q, Haddad LBP, Nacif LS, D’Albuquerque LAC, Lerut J. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg. 2015;15:65.






Case Reports