How do you sequence TIPS and elective umbilical hernia repair in cirrhotic patients with refractory ascites and a reducible hernia to mitigate the early post-TIPS incarceration risk?

Refractory ascites by itself is an indication for TIPS, and even more so if in need of umbilical hernia repair. Resolution of ascites can take 3-4 weeks; however, this is around the time when incarceration can occur due to entrapment of the bowel. Ge et al. looked at the prevalence of this, with about 12.7% developing incarceration after TIPS (Vissa et al., PMID 41452149). I usually coordinate with surgery to have the hernia repaired around 3-4 weeks after TIPS, and potentially sooner if there is flood syndrome or significant thinning of the hernia skin.