Background:

Cirrhotic patients undergoing surgery represent one of the highest-risk groups in perioperative medicine. Portal hypertension, coagulopathy, malnutrition, sarcopenia, cardiopulmonary vulnerability and altered drug handling converge to amplify surgical stress. Managing complications in this population requires a coordinated approach bridging hepatology and surgery.

Objectives:

This narrative review synthesises evidence on surgical risk stratification, perioperative optimisation and complication management in cirrhotic patients, with emphasis on practical algorithms and multidisciplinary strategies.

Methods:

Relevant PubMed-indexed literature, including randomised controlled trials, meta-analyses, cohort studies and consensus guidelines, was reviewed. Reference selection was restricted to 25 authentic, traceable sources, ensuring balanced coverage of pathophysiology, clinical outcomes and recent advances.

Results:

Classical risk scores (Child-Turcotte-Pugh [CTP], model for end-stage liver disease [MELD]) remain useful, but contemporary models such as Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn provide superior calibration by incorporating procedure type and urgency. Preoperative optimisation bundles, including nutrition, ascites control, viscoelastic-guided coagulation management and selective portal decompression, improve outcomes. Major complications include haemorrhage, infection, wound failure, hepatic decompensation, renal dysfunction, cardiopulmonary compromise and venous thromboembolism (VTE). Their frequency and severity increase steeply in emergency versus elective settings. Elective hernia repair and minor resections in optimised, compensated patients are now considered safe, whereas major resections in decompensated cirrhotics remain prohibitive. Emerging strategies, minimally invasive surgery, albumin-based therapies, Terlipressin for renal dysfunction and tailored Enhanced Recovery After Surgery (ERAS) adaptations further mitigate risk.

Conclusions:

Surgical complications in cirrhotics can be anticipated and reduced through structured risk stratification, multidisciplinary optimisation and evidence-based perioperative bundles. The future lies in integrating predictive analytics, minimally invasive approaches and ethical shared decision-making to bridge hepatology and surgery. For practising surgeons, the key message is pragmatic: Complications cannot be ignored, but with anticipation and teamwork, they can increasingly be controlled.