Tieu Brandon H, Cho S David, Luem Nick, Riha Gordon, Mayberry John, Schreiber Martin A
Oregon Health and Science University, Portland, Oregon, USA.
J Trauma. 2008 Oct;65(4):865-70. doi: 10.1097/TA.0b013e31818481f1.
The open abdomen after severe intra-abdominal trauma and emergency surgery is a major operative challenge. It is associated with high morbidity and prolonged hospital stays. Several management strategies have been developed to assist with fascial closure but no single method has emerged as the best. The Wittmann Patch (Starsurgical, Burlington, WI) is a unique device which uses velcro to permit progressive abdominal closure without necessitating serial operations. The purpose of this study was to determine the fascial closure rate using the Wittmann patch. We hypothesized that use of the patch would result in a high closure rate.
Hospital billing codes were reviewed to identify those patients who underwent Wittmann patch placement. During the period from June 2002 to May of 2006, 29 patients were identified. These included 19 trauma patients and 10 other surgical patients. Other patients included vascular, bariatric, and emergency general surgery patients. The trauma registry and the patients' medical records were reviewed to determine injury severity, Acute Physiology and Chronic Health Evaluation II scores, fluid requirements, patch placement, management, and patient outcomes.
Twenty-two (76%) of the 29 patients survived to discharge. The average Acute Physiology and Chronic Health Evaluation II score was 25 +/- 6 in all patients, 22.9 +/- 6 in survivors, and 31 +/- 3 in those who died (p = 0.004). Mean injury severity scale and abdominal abbreviated injury scale scores in trauma patients were 28 +/- 10 and 3 +/- 2, respectively. The mean volume of fluid given during the 24 hours before having an open abdomen or patch placement was 17.6 L +/- 10.1 L. Twenty-five (86.2%) of 29 patients had at least one abdominal operation before placement of the patch (mean 1.3 +/- 1.0). Eighteen (82%) of 22 patients who survived to discharge had successful facial closure. Three patients (14%) required mesh placement for abdominal closure. The remaining patient had his patch removed and ultimately underwent skin grafting and subsequent component separation closure. Successful fascial closure was achieved after 15.5 days +/- 10.2 days (range, 5-42 days). The skin was left open in half of the patients. There were four abdominal complications that were noted while the patch was in place. Three of four complications were related to the primary disease, and in the fourth complication the patch became infected and had to be removed. There were no eviscerations or enterocutaneous fistulas after primary fascial closure. The median length of stay was 28 days (Interquartile range, 14-39 days).
Use of the Wittmann Patch can achieve a high rate of delayed fascial closure in severe trauma and critically ill emergency surgery patients with open abdomens. Most of the complications associated with use of the patch were wound infections after fascial closure and closure of the skin.
严重腹部创伤及急诊手术后的开放性腹腔是一项重大的手术挑战。它与高发病率和延长的住院时间相关。已经开发了几种管理策略来辅助筋膜闭合，但尚未有一种方法成为最佳方法。维特曼补片（Starsurgical，伯灵顿，威斯康星州）是一种独特的装置，它使用尼龙搭扣来实现逐步的腹壁闭合，而无需进行系列手术。本研究的目的是确定使用维特曼补片的筋膜闭合率。我们假设使用该补片将导致高闭合率。
回顾医院计费代码以识别接受维特曼补片放置的患者。在2002年6月至2006年5月期间，识别出29例患者。其中包括19例创伤患者和10例其他手术患者。其他患者包括血管外科、减重外科和急诊普通外科患者。回顾创伤登记和患者的病历以确定损伤严重程度、急性生理与慢性健康状况评估II评分、液体需求量、补片放置、管理和患者结局。
29例患者中有22例（76%）存活至出院。所有患者的平均急性生理与慢性健康状况评估II评分为25±6，存活患者为22.9±6，死亡患者为31±3（p = 0.004）。创伤患者的平均损伤严重程度评分和腹部简明损伤评分分别为28±10和3±2。在出现开放性腹腔或放置补片前24小时内给予的平均液体量为17.6 L±10.1 L。29例患者中有25例（86.2%）在放置补片前至少进行过一次腹部手术（平均1.3±1.0）。22例存活至出院的患者中有18例（82%）成功进行了筋膜闭合。3例患者（14%）需要放置网片进行腹壁闭合。其余患者的补片被移除，最终接受了植皮及随后的成分分离闭合。成功的筋膜闭合在15.5天±10.2天后实现（范围，5 - 42天）。一半的患者皮肤保持开放。在补片放置期间记录到4例腹部并发症。4例并发症中有3例与原发性疾病相关，第4例并发症中补片感染，不得不被移除。初次筋膜闭合后没有发生内脏脱出或肠皮肤瘘。中位住院时间为28天（四分位间距，14 - 39天）。
对于严重创伤和患有开放性腹腔的危重症急诊手术患者，使用维特曼补片可实现较高的延迟筋膜闭合率。与使用该补片相关的大多数并发症是筋膜闭合和皮肤闭合后的伤口感染。
