The Difficult Abdominal Wall. Ziper-type Closure. Wittmann patch. Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction.

Question: On several occasions, our surgeons have performed bowel surgery and have had to leave the abdomen open due to edema, etc. Several days later, the surgeon will return to the OR and place a Wittman patch on the abdomen. The surgeon might go back, still later during the same hospital stay, to close the abdomen. Bescor ptz. How should I code for these? Pennsylvania Subscriber Answer: Initially, you should code the bowel surgery as usual, but append modifier -52 (Reduced services) to indicate that the surgeon did not perform the closure (which is an integral part of all open surgical procedures). Adding modifier -52 will not usually affect your reimbursement, but this does 'leave the door open' for a later procedure to close the abdomen.

Coding for the Wittman patch depends on what, exactly, the surgeon did. For example, the surgeon may sew in a zipper for easy reopening of the abdomen.

This will usually also include an exploration and perhaps lavage before he adds the temporary closure (whether a Wittman patch or a zipper). For this, you should report 49002-58-52 (Reopening of recent laparotomy; Staged or related procedure or service by the same physician during the postoperative period; Reduced services). If the surgeon places the patch without abdominal exploration, you should look instead to an appropriate integumentary system closure code (for instance, 13160, Secondary closure of surgical wound or dehiscence, extensive or complicated), with modifier -58 appended. In this case, as in the above case, the presence of modifier -58 tells the payer that the surgeon planned prospectively for the wound closure. For the final closure, you should once again choose between 49002-58 for closure with exploration, lavage, etc., or 13160-58 for the closure alone with no exploration or lavage.

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 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. 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 Patch closure. 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 Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.