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Purpose: To determine optimal management of and outcome following umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. Methods: A retrospective chart-review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at a single institution from 2002-2008. Univariate, multivariate and Kaplan-Meier analysis was performed.Results: Twenty-one patients had advanced cirrhosis with refractory ascites, of which 15 presented with incarceration and 6 spontaneous umbilical rupture. Fifteen patients were taken to the operating room urgently, and 6 (2 incarceration, 4 umbilical rupture) semi-urgently following placement of a transjugular intrahepatic portosystemic shunt (TIPS). Closed suction drains were utilized in 7 patients. The perioperative mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation and 5 developed ascites related wound complications. Follow-up at a mean of 36-months demonstrated a 20% mortality rate, 5% liver transplantation requirement and 6% hernia recurrence rate. A trend towards decreased wound complications was demonstrated in patients who underwent preoperative TIPS and semi-urgent repair (17% vs. 27%, p=NS). Additionally, TIPS placement postoperatively adequately controlled ascites without additional complication in 2 patients. Use of closed-suction drain versus no drain, did not decrease development of ascites related wound complications (40% vs. 20%, p=0.4), respectively.Following multivariate analysis, spontaneous umbilical rupture was demonstrated to independently correlate with adverse outcome(odds ratio (OR) of 25.0 and 95% confidence interval [1.2-521], p=0.02). Patients with spontaneous umbilical hernia rupture had significantly decreased 36-month transplant-free survival as compared to those with incarcerated hernia (50% vs. 86%, p=0.03). For the 6 patients presenting with umbilical rupture, improved perioperative and 36-month outcome was demonstrated in the 4 patients who underwent preoperative TIPS and semi-urgent repair.Conclusion: Preoperative TIPS placement for patients undergoing semi-elective hernia repair may decrease wound complications, without significantly influencing short or long-term mortality. We recommend semi-elective umbilical herniorrhaphy with preoperative TIPS placement in cirrhotic patients with refractory ascites when feasible.