Diagnosis and management of abdominal wall hernia is a core pathology of the general surgeon’s practice. This common problem is complicated in the setting of end-stage liver disease. To safely treat cirrhotic patients, a complete understanding of the pathophysiology and complicating factors is necessary to maximize outcomes and minimize complications. Increased portal pressure, impaired synthetic function and nutritional deficiencies, impaired tissue strength, accumulation of ascitic fluid, and high intraabdominal pressure set the stage for hernia formation. In the future, more patients with cirrhosis will present for care, requiring management of their hernia. Prior work points to early repair for the right patient, contrary to historical thinking, to avoid catastrophic complications. Patient selection, preoperative optimization of nutrition, coagulopathy, and ascites are critical to minimizing complications. This chapter summarizes the current management and our institutional practice managing a hernia in the end-stage liver disease population.