The Use of the Wittmann Patch Facilitates a High Rate of Fascial Closure in Severely Injured Trauma Patients and Critically Ill Emergency Surgery Patients Brandon H. Tieu, MD, S. David Cho, MD, Nick Luem, MD, Gordon Riha, MD, John Mayberry, MD, and Martin A. Schreiber, MD Background: The open abdomen after severe intra-abdominal trauma and emer- gency surgery is a major operative chal- lenge. It is associated with high morbidity and prolonged hospital stays. Several man- agement strategies have been developed to assist with fascial closure but no single method has emerged as the best. The Witt- mann Patch (Starsurgical, Burlington, WI) is a unique device which uses velcro to per- mit 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. Methods: Hospital billing codes were reviewed to identify those patients who underwent Wittmann patch place- ment. During the period from June 2002 to May of 2006, 29 patients were identi- fied. 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 deter- mine injury severity, Acute Physiology and Chronic Health Evaluation II scores, fluid requirements, patch placement, man- agement, and patient outcomes. Results: Twenty-two (76%) of the 29 patients survived to discharge. The aver- age Acute Physiology and Chronic Health Evaluation II score was 25  6 in all pa- tients, 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 sur- vived to discharge had successful facial closure. Three patients (14%) required mesh placement for abdominal closure. The remaining patient had his patch re- moved and ultimately underwent skin grafting and subsequent component sepa- ration 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 re- moved. There were no eviscerations or enterocutaneous fistulas after primary fascial closure. The median length of stay was 28 days (Interquartile range, 14 –39 days). Conclusions: Use of the Wittmann Patch can achieve a high rate of delayed fascial closure in severe trauma and crit- ically 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. J Trauma. 2008;65:865– 870. T rauma and emergency general surgeons manage open abdomens with increasing frequency in most surgical intensive care units (ICUs) across the United States. Regionalization of trauma centers and advances in operative management of severely injured and critically ill patients partially account for this interesting and often difficult to manage clinical entity. There are several indications for leaving the abdomen open including the need for serial operations as in the case of severe abdominal infections requiring multiple debridements, washouts, or drainage procedures. 1 Patients with acute mes- enteric ischemia or venous congestion may require repeat laparotomies for evaluation of bowel viability and resection. Damage control surgery emphasizes rapid control of hemor- rhage and contamination with the goal of restoring normal physiology rather than normal anatomy necessitating the ab- domen to be left open after the initial operation. Finally, the open abdomen is an important aspect of the treatment of abdominal compartment syndrome (ACS). Traditionally, the open abdomen was managed with a planned ventral hernia approach allowing wounds to granulate followed by split thickness skin coverage ultimately leading to an abdominal wall reconstruction and hernia repair. 2 Although at times it is unavoidable to leave the abdomen open, temporary abdominal wound coverage is required to allow for atraumatic containment of the viscera and control of fluid losses. 2 Several techniques have been described such as skin only closure using towel clips, the Bogota bag using a 3L GU irrigation bag or an X-ray cassette bag, 3 the use of Submitted for publication March 27, 2007. Accepted for publication June 24, 2008. Copyright © 2008 by Lippincott Williams & Wilkins From the Oregon Health and Science University, Portland, Oregon. Presented at the 37th Annual Meeting of the Western Trauma Associ- ation, February 25–March 2, 2007, Steamboat Spring, Colorado. Address for reprints: Brandon H. Tieu, 3181 SW Sam Jackson Park Road, L223A, Portland, OR 97239; email: tieub@ohsu.edu. DOI: 10.1097/TA.0b013e31818481f1 The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 65 • Number 4 865