The Wittmann Patch is a temporary abdominal fascia prosthesis for the planned open abdomen to ease the 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.
History
editThe Wittmann Patch was invented by Dietmar H. Wittmann in 1987 while he was a professor of surgery at the University of Hamburg's School of Medicine in Hamburg Germany. Wittmann continued research on the Wittmann Patch fascia prosthesis in the Department of Surgery at the Medical College of Wisconsin. The fascia prosthesis became commercially available in Europe in 1992 (HIDIH-Surgical) and in the US in 2000 (Starsurgical, Inc).
Synonyms
edit- Fascia Prosthesis,
- Abdominal Fascia Prosthesis,
- Temporary Abdominal Fascia Prosthesis,
- Artificial Bur,
- Bur Patch,
- Abdominal Bur Closure (ABC-Patch)
Trade names
editWittmann Patch (Starsurgical, Inc., Burlington WI)
Indications
editA Acute conditions
- Abdominal compartment syndrome[1]
- Blunt abdominal trauma
- Penetrating abdominal trauma
- Traumatic and non-traumatic intra-abdominal hemorrhage
- Ruptured abdominal aortic aneurysm
- Peritonitis / intra-abdominal infections
- Acute pancreatitis / infected pancreatic necrosis
- Bowel ischemia
B Chronic conditions
- Chronic open abdomen with fistulas
- Chronic open abdomen without fistulas
- Large ventral hernias with fistulas
- Large ventral hernias without fistulas
- Failed ventral hernia repairs with meshes
C Prophylactically to avoid abdominal compartment syndrome
- excessive peritoneal inflammation from abdominal organ transplantation
- excessive peritoneal inflammation from major abdominal operations
Contraindications
editThe patch is not intended for permanent implantation.
Operative technique
editThe original bur as used by Wittmann consists of two sheets of the same size of 40 × 20 cm:
- A softer loop sheet that covers omentum with its tissue-friendly back side – loops facing outwards
- A harder hook sheet on top of the loop sheet – hooks facing inwards to be pressed into the loops
The softer loop sheet is sutured to the right fascia using a running looped #1 Nylon suture. The stitches are 2 cm apart and 2 cm into the fascia and 1–2 cm into the bur to permit good perfusion between stitches. The sheet with loops facing outwards is then pushed between parietal and visceral peritoneum of the other side of the incision covering abdominal content.
Then the harder hook sheet is similarly sutured to the left fascia, and hooks are gently pressed into the loops of the loop sheet.
Generally, the hook sheet is trimmed to fit the size of the open abdomen wound. In case of the massive peritoneal hypertension both sheets cover the open space and the hook sheet does not need trimming to fit the wound opening.
Clinical benefits
edit- Use of the Wittmann Patch in patients allows for a significantly increased rate of delayed primary fascial closure after temporary abdominal closure when compared with a vacuum only closure or the use of a Bogota bag.[2]
- Use of the Wittmann Patch in combination with staged abdominal repair decreases mortality by 20% in patients with APACHE-II score of 20.[3]
References
edit- ^ Stawicki SP, Cipolla J, Bria C (2007). "Comparison of open abdomens in non-trauma and trauma patients: A retrospective study". OPUS 12 Scientist. 1 (1): 1–8.
- ^ Boele Van Hensbroek, P; Wind, J; Dijkgraaf, MG; Busch, OR; Carel Goslings, J (2009). "Temporary closure of the open abdomen: A systematic review on delayed primary fascial closure in patients with an open abdomen". World Journal of Surgery. 33 (2): 199–207. doi:10.1007/s00268-008-9867-3. PMC 3259401. PMID 19089494.
- ^ European Journal of Surgery. 25: 273–84. 1994.
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- Wittmann, DH, Bansal, N, et al. (1994). "Staged abdominal repair compares favorably with conventional operative therapy for intra-abdominal infections when adjusting for prognostic factors with a logistic model". Theoretical Journal of Surgery. 9: 201–207. (now Brit J. Surg.)
Further reading
edit- Wittmann, DH; Bergstein, JM; Aprahamian, C (1989). "Etappenlavage for diffuse peritonitis". Beitr Anäst Intensivemed. 30: 199–221.
- Wittmann, DH; Aprahamian, C; Bergstein, JM (1990). "Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure". World Journal of Surgery. 14 (2): 218–26. CiteSeerX 10.1.1.464.3927. doi:10.1007/BF01664876. PMID 2183485. S2CID 2322945.
- Aprahamian, C; Wittmann, DH; Bergstein, JM; Quebbeman, EJ (1990). "Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma". The Journal of Trauma. 30 (6): 719–23. doi:10.1097/00005373-199006000-00011. PMID 2191142.
- Wittmann, DH; Aprahamian, C; Bergstein, JM; Edmiston, CE; Frantzides, CT; Quebbeman, EJ; Condon, RE (1993). "A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies". The European Journal of Surgery. 159 (2): 75–9. PMID 8098630.
- Wittman, D. H. (2000). "Staged abdominal repair: Development and current practice of an advanced operative technique for diffuse suppurative peritonitis". European Surgery. 32 (4): 171–8. doi:10.1007/BF02949258. S2CID 28224755.
- Keramati, M; Srivastava, A; Sakabu, S; Rumbolo, P; Smock, M; Pollack, J; Troop, B (2008). "The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn". Burns. 34 (4): 493–7. doi:10.1016/j.burns.2007.06.024. PMID 17949916.
- Boele Van Hensbroek, P; Wind, J; Dijkgraaf, MG; Busch, OR; Carel Goslings, J (2009). "Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen". World Journal of Surgery. 33 (2): 199–207. doi:10.1007/s00268-008-9867-3. PMC 3259401. PMID 19089494.