138 Chapter 5 Gastroschisis and omphalocele showed highest incidences of IH compared to the other congenital abdominal anomalies. Both anomalies are characterized by an abdominal wall defect with protruding viscera. In omphalocele, the viscera are covered with a membrane whilst in gastroschisis cases the viscera are not covered and thus more susceptible to infection. In order to surgically repair the defect, the viscera have to be reduced intra-abdominally. The primary goal of surgical repair is to close the defect as soon as possible, as to decrease the risk of infection, whilst simultaneously minimizing the risk of ischemic injury to the viscera due to increased intra-abdominal pressure (IAP) [359-362]. An increase of pressure between 0-15 mmHg is accepted because of the low risk of abdominal compartment syndrome [360]. However, even this increased outwards abdominal pressure during the wound healing process increases fascial tension, which could cause the increased incidence of IH [332]. Since 2004 an alternative method for a select group of patients named sutureless closure was proposed by methods of primary reduction and covering of the gastroschisis defect by watertight dressing and the umbilical cord [363]. This technique supposedly minimizes IAP and allows for spontaneous closure [364]. It is reported that this technique increases the risk of umbilical hernias compared to sutured closure. Still these hernias seem to resolve, not requiring redo surgery and sutureless closure seems to overall entail less complications [348, 365, 366]. This also might be the case for sutured closure. Out of six included studies that reported on redo surgery only 17 of the 31 hernias needed reoperation. It must be noted that most studies did not report on redo surgery. Most gastroschisis cases are isolated conditions, but in 10% associated anomalies like intestinal atresias or necrotizing enterocolitis occur resulting in complex gastroschisis [362]. Our results show that simple gastroschisis has an odds-ratio of 0.18 to develop an IH compared to complex gastroschisis. In general, complex cases are associated with both longer parental nutrition and length of hospital stay [367]. This combination of impaired nutritional status and multiple anomalies could accumulate to a multifactorial cause of increased IH incidence. We have shown that SILO closure increases the risk of IH compared to primary closure. SILO placement is mostly considered when the viscera cannot be reduced into the abdominal cavity because of bowel oedema. This oedema might result in higher IAP leading to an increase in the chances of IH. In a study comparing primary closure with SILO closure it was shown that the incidence of IH increased with longer duration of SILO reduction [332].
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