The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn.

Abstract

Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem.
From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound.
Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up.
In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.

Full text

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The Wittmann PatchTMas a temporary abdominal closure
device after decompressive celiotomy for abdominal
compartment syndrome following burn
Magid Keramatia, Anil Srivastavab,*, Stanley Sakabub, Peter Rumboloc,
Michael Smockc, Jonathon Pollackc, Bryan Troopb
aDepartment of Surgery, St. Louis University Hospital, St. Louis, MO, USA
bDivision of Trauma, St. John’s Mercy Medical Center, St. Louis, MO, USA
cDivision of Burn, St. John’s Mercy Medical Center, St. Louis, MO, USA
1.Introduction
People with extensive burns requiring large-volume fluid
resuscitation are at risk for development of intra-abdominal
hypertension (IAH) and abdominal compartment syndrome
(ACS) [1,2]. ACS mandates decompressive celiotomy to relieve
the multisystem effects of IAH [3–5]. Management of the
consequent open abdomen is challenging despite advances in
critical care medicine.
The purpose of temporary abdominal closure is to protect
the intra-abdominal viscera from mechanical injury, prevent
bowel dessication, minimise abdominal-wall tissue damage,
prevent contamination of the peritoneal cavity and control
egress of peritoneal fluid. Various methods of temporary and
primary abdominal wound closure after clinical improvement
of the patient have been described [6–12], but in most cases
adhesions of intestinal loops to the abdominal wall and
retraction of the fascial edges make closure very difficult or
burns 34 (2008) 493–497
a r t i c l e i n f o
Article history:
Accepted 24 June 2007
Keywords:
Burn
Abdominal compartment syndrome
Celiotomy
Wittmann PatchTM
a b s t r a c t
Background: Abdominal compartment syndrome is frequently the result of aggressive fluid
resuscitation after burn. Management of the open abdomen following decompressive
celiotomy is a major problem.
Methods: From 2004 to mid-2005, six patients required decompressive celiotomy after
developing abdominal compartment syndrome as a result of burn. A Wittmann PatchTM
was used to close the abdominal wound. Patients were re-explored when clinical para-
meters improved and the abdomen was closed, with long-term follow-up for the abdominal
wound.
Results: Of the six patients, five had thermal injury and one had electrical injury. The mean
total body surface area affected for thermal burn was 78% and for electrical burn was 37%.
Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure
and organ dysfunction. The patients were treated with decompressive celiotomy and
Wittmann PatchTMclosure. Survivors subsequently underwent primary abdominal closure,
with no evidence of ventral hernia at long-term follow-up.
Conclusion: In burn cases with abdominal compartment syndrome, a Wittmann PatchTM
may prove a helpful method of temporary abdominal closure, followed by primary closure
with no complications.
# 2007 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: 621 S. New Ballas Road, Suite 560-A, St. Louis, MO, USA. Tel.: +1 314 251 6440; fax: +1 314 251 5745.
E-mail address: aprit@aol.com (A. Srivastava).
0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2007.06.024
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns

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impossible. The morbidity among these cases remains high
and is mostly due to intestinal fistula and ventral hernia
[13,14]. In such cases, closure of the abdominal wall is
performed by split-thickness skin graft over omental or
visceral granulation tissue, as well as reconstruction of the
abdominal wall with flaps or mesh requiring several operative
procedures [15–17].
The Wittmann PatchTM
(Starsurgical, Burlington, WI)
minimises the difficulty in dealing with ongoing fluid losses,
the development of intestinal fistulae and the resulting
massive ventral hernia. This material has been used for
temporary abdominal closure after damage control proce-
dures in trauma and general surgery [18]. The purpose of this
report is to show the efficacy of the Wittmann PatchTMas a
temporary, gradual means for abdominal closure for severely
burned people with abdominal compartment syndrome.
2.Methods
A retrospective review of burn cases requiring decompressive
celiotomy for abdominal compartment syndrome was per-
formed from January 2004 to April 2005 at St. John’s Mercy
Medical Center, a level I trauma and major burn centre.
Diagnosis of compartment syndrome was made on evidence
of bladder pressure above 30 mmHg, using an indwelling
urinary catheter, in association with evidence of renal
dysfunction, cardiopulmonary compromise and haemody-
namic instability. Six patients required temporary abdominal
closure with the Wittmann PatchTM.
The two biocompatible sheets (Fig. 1) of the patch were
sutured to the opposing abdominal fascial edges, as described
by Wittmann et al. [18] by running non-absorbable sutures
(Fig. 2). They were fastened together (Fig. 3) with particular
attention paid to abdominal pressure by monitoring urinary
bladder and peak airway pressures. A suction catheter with
several side-holes cut with scissors was placed over a gauze
pack (Fig. 4), covered with another gauze pack and sealed with
an occlusive dressing to create a vacuum dressing which was
connected to wall suction (Fig. 5). On improvement of their
clinicalsymptoms,patientsunderwentabdominal re-explora-
tion. The patch edges were trimmed and refastened, pulling
the fascial edges closer until a formal tension-free primary
closure was possible. In cases where sepsis developed with
multisystem organ failure, the abdominal cavity was explored
again, peritoneal fluid was obtained for microbiology and the
patch was refastened.
3.Results
Sixpatientsunderwenttemporaryabdominal closurewiththe
WittmannPatchTM.Allweremen,withagesrangingfrom19to
54 years (mean 34 years); five (83%) had sustained thermal
injuriesandone(17%)electricalinjury.Totalbodysurfacearea
burned ranged from 65% to 85% (mean 78%) for thermal
injuries and 37% for electrical injury. All the men required
decompressiveceliotomyaftermassivefluidresuscitationand
subsequent development of ACS. ACS was defined by
hypoxaemia and hypercarbia with elevated peak airway
Fig. 1 – Two sheets of biocompatible material (Wittmann
PatchTM) which adhere to each other.
Fig. 2 – Wittmann PatchTMsutured to fascia with non-
absorbable suture in a running fashion.
burns 34 (2008) 493–497
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pressures, decreased urinary output and elevated intra-
abdominal pressures measured by urinary bladder pressure
(mean 39 mmHg).
Of the six patients, two (33%) survived and four (67%) died.
The cause of death in all four cases was fulminant sepsis with
multisystem organ failure, unrelated to Wittmann PatchTM
placementasconfirmedby re-explorationoftheabdomenand
microbiological examination of peritoneal fluid. For the two
survivors, removal of the Wittmann PatchTMand primary
closure was possible after 9 days (range 8–11 days). During a
follow-up period of at least 14 months, no wound infections,
intestinal fistulae or ventral hernias developed.
4.Discussion
ACS develops as a result of aggressive fluid resuscitation. It is
commonly encountered among people with greater than 70%
body surface area burns, and it carries a very grim prognosis
[1,2]. Elevated intra-abdominal pressures impair cardiac out-
put, the ability to ventilate and splanchnic perfusion [3–5,19].
Although no single pressure is an absolute indication of ACS,
thereis generalagreementthat pressuresexceeding 30 mmHg
are dangerous and that the compartment should be decom-
pressed [20,21]. In our six cases the mean intra-abdominal
pressure was 39 mmHg. Intra-abdominal pressures above
30 mmHg have previously been reported in burn cases with
ACS [1,2,5,30]. However, current literature on ACS suggests
that intra-abdominal pressures between 20 and 25 mmHg
Fig. 3 – Wittmann PatchTMfastened together.Fig. 4 – Wittmann PatchTMcovered with saline-soaked
gauze, with a drainage tube with multiple cut side-holes to
be connected to suction for a vacuum drainage.
Fig. 5 – Wittmann PatchTMsealed with an occlusive
dressing.
burns 34 (2008) 493–497
495

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shouldbedefinedas IAH[1], anddecompressiveceliotomyhas
been recommendedfor intra-abdominal
25 mmHg or more [22,23] to avoid the complications of ACS.
Recently, the World Society on Abdominal Compartment
Syndrome (WSACS) proposed that intra-abdominal pressure
of more than 12 mmHg should be defined as IAH, and intra-
abdominal pressure above 20 mmHg should be treated as ACS
[24]. In this emergent setting, operative decompression is the
treatment of choice [25]. However other methods of decom-
pression have been described [30]. Once the patient’s condi-
tion has stabilised, the next goal andchallenge for the surgeon
should be to re-establish abdominal wall integrity.
An open abdomen is the oldest technique for managing
ACS. Many reports have emphasised the deleterious effects of
leaving the peritoneal cavity exposed. Implications of ongoing
fluid losses, intestinal adhesions, fistula formation and
evisceration are well described [26]. With an open abdomen,
the risk of developing enteric fistula is markedly increased,
occurring in up to 25% of cases [27]. When the peritoneal
contents are left open to the air or when the skin alone has
been closed, the fascial edges retract, making primary closure
difficult or impossible. In these instances, the surgeon has to
use mesh to close the abdominal defect.
The use of synthetic mesh as a closure device is not ideal.
Complications, including infection, seroma formation and
herniadevelopment,havebeendescribedinasmanyas27%of
cases [28]. With synthetic mesh in place the abdomen cannot
be re-explored at the bedside in the intensive care unit (ICU)
should symptoms worsen.
Vacuum-assisted closure devices are expensive forms of
treatment, as the mean duration of therapy is 5 weeks [29] at
approximately $120 per day in our institution. In addition,
there is the added burden to the patient who must undergo
multiple procedures for closure, including split-thickness skin
grafts and local or regional tissue flaps.
The Wittmann PatchTMfor abdominal closure has been
described in trauma literature as producing good results in
comparison with previously used methods [18,25,31]. The
patch was used after celiotomy for our six burn cases with
ACS, but only two survived; four patients died of sepsis with
multisystem organ failure unrelated to Wittmann PatchTM
placement. We were able to complete primary closure of the
fasciaforthetwosurvivors.During14monthsoffollow-up,no
abdominal wound complications were detected.
pressures of
5. Conclusions
According to several reports in the trauma literature as well
our own experience, the Wittmann PatchTMmay prove a
useful method of temporary abdominal closure in burn cases
with ACS. The patch protects the abdominal contents and
offers the convenience of abdominal exploration at the
bedside in the ICU as required. Furthermore, the Wittmann
PatchTManchors the fascia and provides controlled tension to
preventretraction.Onceabdominal
resolved the abdominal fascia can be closed primarily,
avoiding re-operation for large ventral hernias, the sequelae
associated with the use of mesh, and complications with the
abdominal wounds.
hypertensionhas
Conflict of interest statement
The submitted article entitled ‘‘The Wittmann PatchTMas 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. All
authors listed have made substantial contributions to its
creation.No outsidesourcesforfundingwererequired,andno
authors have financial gain in the products used.
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