Wittmann Patch Abdominal Closure

The Wittmann Patch is a temporary abdominal fascia prosthesis for the planned open abdomen to ease management of cases where the abdomen cannot be closed due to abdominal compartment syndrome or because multiple further operations are planned (damage control repair [DCR]). It consists of a sterile hook and a sterile loop sheet made from propylene and nylon. The submitted article entitled “The Wittmann Patch™ as a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn” and its associated figures is an original manuscript which has not been previously published elsewhere and is not under consideration for publication by another editor.

T he infected abdomen poses substantial challenges to surgeons, and often, both temporary and definitive closure techniques are required. Temporary abdominal closure (TAC) allows surgeons ease of re-entry for multiple operations in an infected surgical field. Additionally, temporary closure helps reduce the risk of abdominal compartment syndrome (intra-abdominal hypertension) and its associated morbidity and mortality. Definitive reconstruction can be accomplished eventually in most cases through one of a variety of operative techniques. We review the multiple options available to close the abdominal wall defect satisfactorily during and after the management of complicated intra-abdominal infections. Intra-abdominal infection carries a substantial risk of death, depending largely on the intensity of the patient's systemic response and the extent of the physiologic response, often measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score.

The APACHE II score is a well-established and validated method by which to stratify risk in patients with intra-abdominal infections [,]. The goals of clinical management of intra-abdominal infections include control of bacterial or toxin sources, maintaining organ system function, and quelling the resultant inflammatory process []. Occasionally, multiple laparotomies are required to eradicate intra-abdominal bacterial sources. This approach should be undertaken only when definitive closure of the abdomen is not possible initially. Performing re-laparotomy on demand, compared with planned re-laparotomy, yields a higher rate of anastomotic leakage, lower incisional hernias, and all surgery-related complications (intra-abdominal abscess, fistula, hemorrhage, perforation) [].

In a sense, leaving the abdomen open in peritonitis is similar to the damage control approach for trauma. Leaving the abdomen open not only enables multiple operations but also helps prevent abdominal compartment syndrome. Perioperative fluid resuscitation of the patient leads frequently to visceral and retroperitoneal edema, ischemic fascia, and abdominal compartment syndrome.

An intra-abdominal pressure >30 cm H 2O can result in decreased venous return and cardiac collapse, leading to multiple organ dysfunction syndrome, especially of the pulmonary, cardiovascular, renal, splanchnic, and central nervous systems (CNS). Temporary abdominal closure with a bridged biologic mesh or synthetic system (e.g., Wittmann Patch, Bogota bag, vacuum-assisted closure [VAC device], synthetic mesh) between the fascial edges can help prevent abdominal compartment syndrome while preserving the fascial for eventual closure.

In the setting of known compartment syndrome and intra-abdominal infection, VAC device, the Wittmann Patch, or a synthetic mesh allow flexibility in bedside adjustment as needed. Each system is described with and without the use of negative pressure devices (). Wittmann Patch The Wittmann Patch (STARSURGICAL, Inc., Burlington, WI) was designed to allow adjustment in the laxity or redundancy of the closure material to accommodate changes in intra-abdominal pressure and prevent abdominal compartment syndrome. As described by Wittmann et al. In 1993, the patch consists of sheets of biocompatible polyamide and polypropylene, one containing multiple micro-mushrooms (hooks) and the other multiple slings (loops), enabling them to stick together similar to Velcro ® []. They are anchored to the midline fascia with running non-absorbable suture, generally with the loop sheet sutured to the left fascia, and then fastened together in the midline.

With the resolution of visceral edema, the excess material can be removed, and gradually, the fascial edges may be approximated. This system facilitates re-operation and helps prevent lateral retraction of the fascial edges, thereby aiding definitive delayed primary closure of the fascia. Several studies have demonstrated that this technique ultimately increases the rate of delayed fascial closure after laparotomy. In one series of 103 open abdomens managed with the Wittmann Patch, 78% of patients were able to have delayed primary closure compared with 30% of those who did not receive the patch (p. Bogota Bag The Bogota bag was first described by Oswaldo Borraez in Bogota, Colombia. Fiat diagnostic software free download. To perform this technique, a sterile plastic 3-L genitourinary irrigation fluid bag is sutured to the fascial edges for TAC.