178 Chapter 7 Discussion This study, which includes over 2000 infants and 43 anomalies in a span of 20 years, is the first to have sufficient power to describe the incidence of and risk factors for incisional hernia in infants. The incidence of IH in our cohort is 5.2%, which increases to 7.0% if only cases with a follow-up of at least one year are taken into account. One in seven of these hernias resolves without surgery. Out of all included diseases, those suffering from necrotizing enterocolitis, gastroschisis and omphalocele seem to be most at risk. However, large variation between diseases exists. Wound infection, a history of prematurity, and a history of stoma are significant risk factors for IH development in our cohort. Before interpretating our results we want to point out that studies reporting on the incidence of IH are greatly influenced by the inclusion criteria which build up the cohort of patients. Therefore, it is of key importance to evaluate which diseases make up the overall cohort (Appendix 1). Since we chose to include only operated infants who were no older than three years of age, the proportion of high-risk diseases is higher compared to studies that also included older paediatric cases. This could explain why we report a higher IH-incidence compared to previous studies [6, 7]. Infantile Hypertrophic pyloric stenosis (PS) has been suggested as a high-risk disease for the development of IH [6, 7]. However, the incidence of IH following PS in our cohort is only 4%. Since PS is a common disease in young children, it will make up a large proportion of most paediatric or infantile cohorts [14]. In our cohort 20% of the infants were operated because of PS. Consequently, it is understandable that a significant proportion of the total count of IHs will be provided by PS: in our cohort this amounts to 16% (N=17/104). Moreover, it seems that IHs following PS might be different from the other IHs. IHs following PS are overrepresented in early IHs and IHs following laparoscopy. In laparoscopically treated PS, omental herniation during instrument removal and not suturing the fascia of the port-site have been determined to cause IHs [19]. It seems advisable to suture the fascia of each trocar port. The development of a wound infection seems to be the most important risk factor for IH in infants, which is in line with studies conducted with adults [15]. Therefore, reducing wound infections might lead to a reduction of IHs. Preoperative antibiotics have undeniably reduced the occurrence of wound infection in adults [16]. In paediatric patients, proper administration of preoperative antibiotics is also widely accepted as one of the few risk factors which can be influenced [17]. However, ambiguity on this effect exists in neonates [18]. This is possibly explained by a lack of appropriate timing
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