Umbilical herniation is common in patients with liver cirrhosis and ascites. Rarely, they suffer from incarceration and strangulation of the umbilical hernia after treatment of ascites. We report 3 cases of umbilical hernia incarceration following removal of massive ascites with different treatment modalities. Physicians managing this group of patients should be aware of this rare and potentially fatal complication. 1. Introduction Ascites is a common complication of liver cirrhosis. There is an increased incidence of umbilical hernia in patients with liver cirrhosis and ascites [1]. Most patients remain asymptomatic and rarely develop complications such as leakage, ulceration, spontaneous rupture, or incarceration [2]. Incarceration of umbilical hernia in cirrhotics is rare but is known to occur after treatment of ascites [2]. In this paper, we document development of incarcerated or symptomatic umbilical hernia in three patients being treated for ascites, two of which resulted in acute abdomen requiring emergency surgery. 2. Case Report 2.1. Case 1 This patient was a 59-year-old woman with Child’s B cryptogenic liver cirrhosis complicated by massive diuretic-intractable ascites. Despite high doses of diuretics (spironolactone 300？mg OM and frusemide 100？mg OM), she continued to require frequent large volume paracentesis for symptomatic relief. Her diuretic dose could not be increased further due to development of diuretic-induced renal impairment and hyperkalemia, and she was managed with recurrent large volume paracentesis. Over a period of 4 months, she required monthly large volume paracentesis totaling 22 litres. She was noted to have an umbilical hernia but was asymptomatic. The patient was recommended but declined liver transplantation. In view of persistent diuretic-intractable ascites and frequent need for large-volume paracentesis, the patient underwent insertion of a transjugular intrahepatic portosystemic shunt (TIPS) for treatment of her refractory ascites. Baseline hepatic venous pressure gradient was markedly elevated at 22？mmHg. An abdominal coop loop was inserted the day prior to the TIPS insertion for complete drainage of ascites. TIPS was performed uneventfully with a reduction in the portosystemic gradient to 11？mmHg after TIPS. On the second day after the TIPS procedure, the patient complained of abdominal discomfort, nausea, and vomiting. Clinical examination revealed a tender irreducible umbilical hernia. Urgent computed tomography scan of the abdomen demonstrated an incarcerated umbilical hernia with dilated small bowel loops
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