The tendency for patients with severe liver disease to develop an umbilical hernia has been known for some time.1,2 The denominator is hard to determine, but review of patients referred for consideration of liver transplantation shows that approximately 20% have an umbilical hernia.3 Unlike the general population, in which female sex and obesity are risk factors for umbilical hernia, patients with liver disease who form umbilical hernias are more likely to be men with muscle wasting and ascites. Although the sex difference probably reflects the incidence of cirrhosis, men with liver disease are more likely to develop hernia at the umbilicus than the inguinal canal, unlike the general population, in which the opposite is true. The reason for this is not clear because the contributory factors, abdominal distension and abdominal wall weakness, are as likely to promote an inguinal hernia as an umbilical hernia. A personal hypothesis is that portosystemic venous communication at the umbilicus transmits the additional pressure required to favor herniation to the umbilicus rather than the groin. An umbilical hernia often is accompanied by marked thrombocytopenia, even before ascites is evident. If true, it has important implications in planning the repair of an umbilical hernia in cirrhotic patients.