The Open Abdomen in Damage Control Surgery

  • Jeff Garner
  • Rao R. Ivatury


The open abdomen is an integral part of the damage control surgical philosophy although it does present its own physiological penalties; it is therefore vital that as much attention is paid to the management of the open abdomen as the other aspects of DCS and the surgeon must have a full range of techniques at their command. The predominant reason for an open abdomen in DCS is to avoid the deleterious effects of raised intra-abdominal pressure such as reduced splanchnic and renal blood supply, splinting of the diaphragm with reduced tidal volume and reduced venous return.

When the abdomen is left open, the muscle fibres shorten and retract, and the viscera begin to adhere to the underside of the abdominal wall, so the key to open abdomen management is a temporary abdominal closure that minimises loss of domain and prevents adhesion formation. A variety of techniques are available, and the method chosen should reflect the local availability of equipment and skills of the surgeon. Silo methods such as the Bogota bag should only be used if nothing else is available as the techniques of choice are some sort of medial fascial traction and topical negative pressure dressings either individually or preferably in combination.

The outcomes following temporary abdominal closure are highly variable, but definitive fascial closure rates of up to 90% are achievable; complications include failure to achieve fascial closure, fistulation and subsequent incisional hernia aside from mortality which is largely attributable to the underlying traumatic injuries.


  1. 1.
    Ogilvie WH. The late complications of abdominal war wounds. Lancet. 1940;2:253–6.CrossRefGoogle Scholar
  2. 2.
    Vargo D, Richardson D, Campbell A, et al. Management of the open abdomen: from initial operation to definitive closure. Am Surg. 2009;75(11):S1–S22.Google Scholar
  3. 3.
    Cheatham ML, Safcsak K, Llerena LE, Morrow CE Jr, Block EF. Long-term physical, mental and functional consequences of abdominal decompression. J Trauma. 2004;56:237–41.CrossRefPubMedGoogle Scholar
  4. 4.
    Malbrain MLNG, Cheatham ML, Kirkpatrick A, et al. Results from an international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. Definitions. Intensive Care Med. 2006;32:1722–32.CrossRefPubMedGoogle Scholar
  5. 5.
    Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39(7):1190–206.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Saggi BH, Sugerman HJ, Ivatury RR, et al. Abdominal compartment syndrome. J Trauma. 1998;45(3):597–609.CrossRefPubMedGoogle Scholar
  7. 7.
    Simon RJ, Friedlander MH, Ivatury RR, et al. Hemorrhage lowers the threshold for intra-abdominal hypertension-induced pulmonary dysfunction. J Trauma. 1997;42(3):398–403.CrossRefPubMedGoogle Scholar
  8. 8.
    Sugrue M, Buist D, Hurihan F, et al. Prospective study of intra-abdominal hypertension and renal function after laparotomy. Br J Surg. 1995;82:235–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Doty JM, Oda J, Ivatury RR, et al. the effects of hemodynamic shock and increased intra-abdominal pressure on bacterial translocation. J Trauma. 2002;52(1):13–7.PubMedGoogle Scholar
  10. 10.
    Diebel L, Saxe J, Dulchavsky S. Effect of intra-abdominal pressure on abdominal wall blood flow. Am Surg. 1992;58:573–6.PubMedGoogle Scholar
  11. 11.
    Hong JJ, Cohn SM, Perez JM, Dolich MO, Brown M, McKenney MG. Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg. 2002;89(5):591–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Chen J, Ren J, Zhang W, Li J. Open versus closed abdomen treatment on liver function in rats with sepsis and abdominal compartment syndrome. J Trauma. 2011;71(5):1319–25.CrossRefPubMedGoogle Scholar
  13. 13.
    Kirkpatrick AW, Roberts DJ, Faris PD, et al. Active negative pressure peritoneal therapy after abbreviated laparotomy. Ann Surg. 2015;262:38–46.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Leppaniemi A, Mentula P, Hienonen P, Kemppainen E. Transverse laparotomy is feasible and effective in the treatment of abdominal compartment syndrome in severe acute pancreatitis. WJES. 2008;3:6. Scholar
  15. 15.
    Björck M, Kirkpatrick AW, Cheatham M, Kaplan M, Leppäniemi A, De Waele JJ. Amended classification of the open abdomen. Scand J Surg. 2016;105(1):5–10.CrossRefPubMedGoogle Scholar
  16. 16.
    Rezende-Neto JB, Moore EE, Melo de Andrade MV, et al. Systemic inflammatory response secondary to abdominal compartment syndrome: stage for multiple organ failure. J Trauma. 2002;53:1121–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Cheatham ML, Safcsak K, Brzezinski SJ, et al. Nitrogen balance, protein loss and the open abdomen. Crit Care Med. 2007;35:127–31.CrossRefPubMedGoogle Scholar
  18. 18.
    Huang Q, Ki J, Lau W-Y. Techniques for abdominal wall closure after damage control laparotomy: from temporary closure to early/delayed fascial closure: a review. Gastro Res Prac. 2016;2016:15. Scholar
  19. 19.
    de Waele JJ, Leppaniemi AK. Temporary abdominal closure techniques. Am Surg. 2011;77:S46–50.PubMedGoogle Scholar
  20. 20.
    Tremblay LN, Felciiano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg. 2001;182:670–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012;36:497–510.CrossRefPubMedGoogle Scholar
  22. 22.
    Wilde JM, Loudon MA. Modified Opsite® sandwich for temporary abdominal closure: a non-traumatic experience. Ann R Coll Surg Engl. 2007;89:57–61.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Brock WB, Barker DE, Burns RP. Temporary closure of open abdominal wounds: the vacuum pack. Am Surg. 1995;61:30–5.PubMedGoogle Scholar
  24. 24.
    Chen SZ, Li J, Li XY, et al. Effects of vacuum-assisted closure on wound microcirculation: an experimental study. Asian J Surg. 2005;28:211–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Moues CM, Vos CM, Bend GJ, et al. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen. 2004;12:11–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Carlson GL, Patrick H, Amin AI, et al. Management of the open abdomen: a national study of clinical outcomes and safety of negative pressure wound therapy. Ann Surg. 2013;257(6):1154–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Wittman DH. Staged abdominal repair: development and current practice of an advanced operative technique for diffuse suppurative peritonitis. Acta Chir Austricaca. 2000;32:171–8.Google Scholar
  28. 28.
    Petersson U, Acosta S, Bjorck M. Vacuum-assisted wound closure and mesh-mediated fascial traction: a novel technique for late closure of the open abdomen. World J Surg. 2007;31:2133–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Reamer MW, Yelle J-D, Reitsma B, Doumit G, Allen MA, Bell MS. Management of open abdominal wounds with a dynamic fascial closure system. Can J Surg. 2008;51(3):209–14.Google Scholar
  30. 30.
    Diaz JJ Jr, Dutton WD, Ott MM, et al. Eastern association for the surgery of trauma: a review of the management of the open abdomen: part 2 “Management of the open abdomen”. J Trauma. 2011;71(2):502–12.CrossRefPubMedGoogle Scholar
  31. 31.
    Rencuzogullari A, Dalci K, Eray IC, et al. Comparison of early surgical alternatives in the management of the open abdomen: a randomised controlled study. Ulus Travma Acil Cerrahi Derg. 2015;21(3):168–74.CrossRefPubMedGoogle Scholar
  32. 32.
    Long KL, Hamilton DA, Davenport DL, Bernanrd AC, Kearney PA, Chang PKA. prospective controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared to VAC alone in the management of an open abdomen. Am Surg. 2014;80(6):567–71.PubMedGoogle Scholar
  33. 33.
    Correa JC, Meija DA, Duque N, Montoya JM, Uribe CM. Managing the open abdomen: negative pressure closure versus mesh-mediated fascial traction closure: a randomized trial. Hernia. 2016;20(2):221–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Bee TK, Croce MA, Magnotti LJ, et al. Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma. 2008;65(2):337–42.CrossRefPubMedGoogle Scholar
  35. 35.
    Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg. 2014;12:1105–14.CrossRefPubMedGoogle Scholar
  36. 36.
    Quyn AJ, Johnston C, Hall D, et al. The open abdomen and temporary abdominal closure systems: historical evolution and systematic review. Colorectal Dis. 2012;14(8):e429–38.CrossRefPubMedGoogle Scholar
  37. 37.
    DuBose JJ, Scalea TM, Holcomb JB, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American association for the surgery of trauma multicentre study. J Trauma Acute Care Surg. 2013;74:113–22.CrossRefPubMedGoogle Scholar
  38. 38.
    Pommerening MJ, DuBose JJ, Zielinski MD, et al. Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy. Surgery. 2014;156:431–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Bradley MJ, DuBose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST open abdomen registry. JAMA Surg. 2013;148(10):947–54.CrossRefPubMedGoogle Scholar
  40. 40.
    Boele van Hensbroek P, Wind J, Dijkgraaf MGW, Busch ORC, Goslings JC. Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg. 2009;33:199–207.CrossRefPubMedGoogle Scholar
  41. 41.
    Navsaria P, Nicol A, Hudson D, Cockwill J, Smith J. Negative pressure wound therapy management of the “open abdomen” following trauma: a prospective study and systematic review. World J Emerg Surg. 2013;8:4.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Cirocchi R, Birindelli A, Biffl WL, et al. What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis. J Trauma Acute Care Surg. 2016;81:575–84.CrossRefPubMedGoogle Scholar
  43. 43.
    Chiara O, Cimbanassi S, Biffl W, et al. International consensus conference on open abdomen in trauma. J Trauma Acute Care Surg. 2016;80:173–83.CrossRefPubMedGoogle Scholar
  44. 44.
    Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39:912–25.CrossRefPubMedGoogle Scholar
  45. 45.
    Sharrock AE, Barker T, Yuen HM, Rickard R, Tai N. Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis. Injury. 2016;47:296–306.CrossRefPubMedGoogle Scholar
  46. 46.
    Poulakidas S, Kowal-Vern A. Component separation technique for abdominal wall reconstruction in burn patients with decompressive laparotomies. J Trauma. 2009;67:1435–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Brandl A, Laimer E, Perathoner A, Zitt M, Pratschke J, Kafka-Ritsch R. Incisional hernia rate after open abdomen treatment with negative pressure and delayed primary fascia closure. Hernia. 2014;18:105–11.CrossRefPubMedGoogle Scholar
  48. 48.
    Willms A, Schaaf S, Schwab R, et al. Abdominal wall integrity after open abdomen: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Hernia. 2016;20:849–58.CrossRefPubMedGoogle Scholar
  49. 49.
    Zosa BM, Como JJ, Kelly KB, He JC, Claridge JA. Planned ventral hernia following damage control laparotomy in trauma: an added year of recovery but equal long-term outcome. Hernia. 2016;20:231–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Burlew CC, Moore EE, Cuschieri J, et al. Who should we feed? A western trauma association multi-institutional study of enteral nutrition in the open abdomen after injury. J Trauma Acute Care Surg. 2012;73:1380–8.CrossRefPubMedGoogle Scholar
  51. 51.
    Divarci E, Karapinar B, Yalaz M, Ergun O, Celik A. Incidence and prognosis of intraabdominal hypertension and abdominal compartment syndrome in children. J Pediatr Surg. 2016;51:503–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Gutierrez IM, Gollin G. Negative pressure wound therapy for children with an open abdomen. Langenbecks Arch Surg. 2012;397:1353–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Jeff Garner
    • 1
  • Rao R. Ivatury
    • 2
  1. 1.The Rotherham NHS Foundation TrustRotherhamUK
  2. 2.Virginia Commonwealth UniversityRichmondUSA

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