Artificial Bur

The scientific name of the device that has been used in the literature is Artifical Bur (or Velcro Analogue) and Artifical Bur Closure.  In recent publications the name Artificial Bur Closure is preferred because the mechanism of adhesion has been copied from nature and is similar to the adhering mechanism of the fruit of certain plants of the genus Arctium (Arctium lappa, Arctium tomentosum etc.

Common terms for these plants are bur, burdock breech, stick tight, and cocklebur.  I discourage the use of propriatory names and recommend using the generic name artificial bur, artificial bur closure or simply bur closure. 

For surgical use as fascia prosthesis the term Bur Fascia Prosthesis describes most accurately its use.

Physical and Bacteriological Properties

The results of measuring the physical properties of the artificial bur with regard to tensile strength (before and after sterilization) and before & after 5 uses are described in the paper A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies.¹ 

Only tangential force, not vertical pull, surpassed manifold the force required to disrupt a native fascia.

The results of bacterial colonization, growth, and adherence to the polypropylene and polyamide material using special sonication technique for bacterial recovery showed no measurable risk to the patient.  The testing was done before I regularly applied the Hypopack to prevent additional contamination.  In this scenario exogenous contamination from outside was possible.  Even under this condition we were not able to show any enhancement of bacterial colonization of the bur and wound.  Cultures of the bur and the peritoneum showed the same bacterial pattern.

We also measured bacterial counts within the peritoneal fluid after 24, 48, and 72 hours and results showed that within 24 hours after irrigation of the peritoneum, bacterial counts were back to their original value.  This finding supports the 24 interval between STAR entries in cases of intra-abdominal infection^2,3.

 

History of Use for Temporary Fascia Prosthesis

I had the idea to use a hook and loop fastener in 1987 during one of my lectures in Asia.  Back at home I tried to find the material.  It was not easy because vendors were very secretive and did not want to provide any proprietary information.  Finally my drapery gave me samples and I sterilized the material and began using it.  During this time I was invited to join Dr. Condon’s faculty at the department of Surgery at the Medical College of Wisconsin.  Here I wrote a study protocol that was first approved by our IRB than later rejected because I needed an FDA device exemption.  Trying to obtain a device exempt from the FDA turned out to be extremely difficult because the FDA requested data from clinical studies which I could not provide because the IRB would not let me do the study without the device exemption. 

I independently collected data from my patients and entered the data into a register.  Patients or families were always consulted prior to the STAR procedure and gave informed consent.  At this time fellow surgeons became aware of the efficacy of the device and started requesting samples which I couldn't initiallty provide.

Finally a group consisting of Dr. Copper - Dean of the Medical College, Dr. Condon - Chairman of our department, a legal consultant and I decided that I should use the device on a compassionate basis and abide by the guidelines I had provided in my study protocol for the IRB that was initially approved.

In 1988 I took the patient information and analysis of results to the FDA and obtained approval to use the device in patients for temporary abdominal closure.

References

¹ Wittmann DH, Aprahamian C, Bergstein JM et al. A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies. Eur J Surg 1993;159(2):75-79
² Edmiston CE, Jr., Goheen MP, Kornhall S, Jones FE, Condon RE. Fecal peritonitis: microbial adherence to serosal mesothelium and resistance to peritoneal lavage. World J Surg 1990;14(2):176-183
³ Wittmann DH. Operative and nonoperative therapy of intraabdominal infections. Infection 1998;26(5):335-341

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STAR Hypopack

Before 1991 we used normal dressing on the abdominal wound of STAR patients.  I did extensive bacteriological studies to evaluate bacterial contamination of wound and the artificial bur and published the results in the early 1990's^1,2,3.  Based on my experience in orthopedic surgery in which we used adhesive drapes to cover the operating field in hip joint replacement surgery in Germany, I started using the drape in STAR patients to prevent exogenous contamination between two STAR entries.  Initially I had challenges with leakage between the skin and the drape.  This was solved by applying negative pressure within the wound using a drain and a suction pump at the end of the operation which resulted in a hard, clean dressing that was easy to handle.  The ICU nurses loved that the Hypopack prevented peritoneal fluid spilling ont the bed and floor.   Today this remains the simplest and most cost effective method of creating a hypobaric wound dressing for the STAR procedure.

The Hypopack also enabled the collection of peritoneal fluid as a basis for meaningful replacement therapy of protein losses with FFP^4,5,6.  The peritoneal fluid was now available for research purposes in high risk patients with sepsis & defense failure syndrome^6,7,8 and measurement of antibiotic concentration at the site of infection⁹.

References

¹ Wittmann DH, Bergstein JM, Frantzides C. Calculated empiric antimicrobial therapy for mixed surgical infections. Infection 1991;19 Suppl 6:S345-S350
² Wittmann DH, Syrrakos B, Wittmann MM. Advances in the diagnosis and treatment of intra-abdominal infection. In: Nyhus L, Nichols RL, editors. Problems in General Surgery: Surgical Sepsis, 1992 and beyond. 10 ed. Philadelphia: J.B. Lippincott Company; 1993:604-627
³ Wittmann DH, Aprahamian C, Bergstein JM et al. A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies. Eur J Surg 1993;159:75-79
⁴ Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Ann Surg 1996;224(1):10-18
⁵ Wittmann DH. Newer methods of operative therapy for peritonitis. In: Nyhus LM, Baker RJ, Fischer JE, editors. Mastery of Surgery. 3 ed. Boston: Little, Brown and Company; 1996:146-152
⁶ Wittmann DH. Operative and non-operative therapy of intraabdominal infections. Infection 1998;26(5):335-341
⁷ Wittmann DH, Wittmann AM. Scope and limitations of antimicrobial therapy of sepsis in surgery. Langenbecks Arch Surg 1998;383(1):15-25
⁸ Aprahamian C, Schein M, Wittmann D. Cefotaxime and metronidazole in severe intra-abdominal infection. Diagn Microbiol Infect Dis 1995;22(1-2):183-188
⁹ Schein M, Wittmann DH, Holzheimer R, Condon RE. Hypothesis: compartmentalization of cytokines in intra-abdominal infection. Surgery 1996;119(6):694-700

Other References

Körte. Tharapie der Peritonitis. Grenzgebieten der Med u Chir 1897
Wittmann DH, Goris RJA, Rangabashyam N, Sayek I. Laparostomy, open abdomen, etappenlavage, planned relaparotomy and staged abdominal repair: too many names for a new operative method. In: Ruedi, editor. State of the Art of Surgery. Reinach, Switzerland: International Society of Surgery; 1994:23-27
Wittmann DH, Wallace JR, Schein M. Open abdomen, planned relaparotomy, or staged abdominal repair: is there a difference? World J Surg 268, S49. 1994