Open Abdomen: Indications, Surgical Management, and Critical Care

  • Stefania Cimbanassi
  • Osvaldo ChiaraEmail author


Open abdomen (OA) is a condition in which at the end of laparotomy, performed whether for trauma or for non-trauma surgical emergencies, the fascial edges are left purposefully open, in order to avoid the increase of intra-abdominal pressure (IAP) and the onset of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), to allow abdominal planned re-exploration(s) (PR), or to manage intra-abdominal infections, in a stepwise approach. This strategy induces dramatic changes in patient’s physiology and may render the patient prone to the onset of complications, such as development of the entero-atmospheric fistula. Due to the complexity of this peculiar clinical setting, doctors who treat OA patients must be aware about the correct indications at the indicative laparotomy, technical elements for temporary abdominal closure (TAC), strategies for fistula takedown, and definitive reconstruction of the abdominal wall, in addition to the elements of critical care. This chapter, written by authors with a wide experience in the management of OA patients, is an updated and concise but comprehensive overview encompassing all the technical aspects of the problem, and it may represent a useful tool for all surgeons, intensivists, and nurses who take care of patients with an open abdomen.


  1. 1.
    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.CrossRefGoogle Scholar
  2. 2.
    Rotondo MF, Schwab CW. Damage control: an approach for improved survival in exsanguinating penetrating abdominal trauma. J Trauma. 1993;45:914–21.Google Scholar
  3. 3.
    Van Ruler O, Mahler CV, Boer KR, et al. Comparison of on-demand vs planned relaparotomy in patients with severe peritonitis. A randomized trial. JAMA. 2007;298:865–72.CrossRefGoogle Scholar
  4. 4.
    Cheatham ML, Malbrain MNG, Kirkpatrick A, et al. Results from international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. II recommendations. Intensive Care Med. 2007;33:951–62.CrossRefGoogle Scholar
  5. 5.
    Bjorck M, Bruhin A, Cheatham M, et al. Classification important step to improve management of patients with an open abdomen. World J Surg. 2009;33:1154–7.CrossRefGoogle Scholar
  6. 6.
    Kirkpatrick AW, Roberts DJ, De Waele JD, 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;39:1190–206.CrossRefGoogle Scholar
  7. 7.
    Bjorck M, Kirkpatrick AW, Cheatham M, et al. Amended classification of the open abdomen. Scand J Surg. 2016;105:5–10.CrossRefGoogle Scholar
  8. 8.
    Bjarnason T, Montgomery A, Acosta S, et al. Evaluation of the open abdomen classification system: a validity and reliability analysis. World J Surg. 2014;38:3112–24.CrossRefGoogle Scholar
  9. 9.
    Kafka-Ritsch R, Zitt M, Schorn N, et al. Open abdomen treatment with dynamic sutures and topical negative pressure resulting in a high primary fascial closure rate. World J Surg. 2012;36:1765–71.CrossRefGoogle Scholar
  10. 10.
    Chiara O, Cimbanassi S, Negreanu J. Methods for temporary abdominal closure. In: Chiara O, Cimbanassi S, editors. Atlas of open abdomen in trauma-how I do it. Minerva Medica; 2017. p. 11–8.Google Scholar
  11. 11.
    Ryczerc AM, Slack P, McNulty AK. Distribution assessment comparing continuous and periodic wound instillation in conjunction with negative pressure wound therapy using an agar-based model. Int Wound J. 2013;10:214–20.CrossRefGoogle Scholar
  12. 12.
    Roberts DJ, Zygun DA, Grendar J, et al. Negative pressure wound therapy for critically ill adults with open abdominal wound: a systematic review. J Trauma Acute Care Surg. 2012;73:629–39.CrossRefGoogle Scholar
  13. 13.
    Vargo D, Richardson D, et al. Management of the open abdomen: from initial operation to definitive closure. Am Surg. 2009;75:S1–S22.Google Scholar
  14. 14.
    Keramati M, Srivastava A, Sakabu S, et al. The Wittmann patch™ as a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burns. Burns. 2008;34:493–7.CrossRefGoogle Scholar
  15. 15.
    Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of temporary abdominal closure: a 7-years experience with 112 patients. J Trauma. 2000;48:201–6.CrossRefGoogle Scholar
  16. 16.
    Rasilainen SK, Mentula PJ, Leppaniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg. 2012;99:1725–32.CrossRefGoogle Scholar
  17. 17.
    Lindstedt S, Malmsjo M, Helbowicz J, et al. Comparative study of microvascular blood flow in the intestinal wall, wound contraction and fluid evacuation during negative pressure therapy in laparostomy using V.A.C abdominal dressing and ABThera™ open abdomen negative pressure therapy system. Int Wound J. 2013;10:411–7.CrossRefGoogle Scholar
  18. 18.
    Patel NY, Cogbill TH, Kallies KJ, et al. Temporary abdominal wall closure: long term outcomes. J Trauma. 2011;65:337–42.Google Scholar
  19. 19.
    Ouellet JF, Ball CG. Recurrent abdominal compartment syndrome induced by high negative pressure abdominal closure dressing. J Trauma. 2011;71:785–6.CrossRefGoogle Scholar
  20. 20.
    Wainstein DE, Tungler V, Ravazzola C, et al. Management of external small bowel fistulae. Challenges and controversies confronting the general surgeon. Int J Surg. 2011;9:198–203.CrossRefGoogle Scholar
  21. 21.
    Chiara O, Cimbanassi S. Entero-atmospheric fistula(s). In: Chiara O, Cimbanassi S, editors. Atlas of open abdomen in trauma-how I do it. Minerva Medica; 2017. p. 26–40.Google Scholar
  22. 22.
    Subramanian MH, Liscum KR, Hirshberg A. The floating stoma: a new technique for controlling exposed fistula in abdominal trauma. J Trauma. 2005;53:386–8.CrossRefGoogle Scholar
  23. 23.
    Layton B, DuBose J, Nichols S, et al. Pacifying the open abdomen with concomitant intestinal fistula: a novel approach. Am J Surg. 2010;190:e48–50.CrossRefGoogle Scholar
  24. 24.
    Jannasch O, Chiapponi C, Tautenhahn J, et al. The fistula adapter, an evolving device in treatment of entero-atmospheric fistulae. Negat Pressure Wound Ther. 2014;1:112–4.Google Scholar
  25. 25.
    Goverman J, Yelon JA, Platz JJ, et al. The “Fistula VAC”, a technique for management of enterocutaneous fistula arising within the open abdomen: a report of 5 cases. J Trauma. 2006;60:428–31.CrossRefGoogle Scholar
  26. 26.
    Ramsay PT, Mejia VA. Management of entero-atmospheric in the open abdomen. Am Surg. 2010;76:637–9.PubMedGoogle Scholar
  27. 27.
    Verhaalen A, Walkins B, Brasel K. Techniques and cost effectiveness of enteroatmospheric fistula isolation. Wounds. 2010;22:212–7.PubMedGoogle Scholar
  28. 28.
    Ramirez OA, Ruas E, Dellon AL. “Component separation” method for closure of abdominal wall defects: an anatomic and clinical study. Plast Reconstruct Surg. 1990;86:519–26.CrossRefGoogle Scholar
  29. 29.
    Burlew CC, Moore EE, Biffl WL, et al. One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma. 2012;72:235–41.Google Scholar
  30. 30.
    Salman AE, Yetisir F, Aksoy M, et al. Use of dynamic closure system in conjunction with vacuum assisted closure therapy in delayed closure of open abdomen. Hernia. 2014;18:99–104.CrossRefGoogle Scholar
  31. 31.
    Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am. 2013;93:1111–3.CrossRefGoogle Scholar
  32. 32.
    Tukiainen E, Leppaniemi A. Reconstruction of extensive abdominal wall defects with microvascular tensore fascia latae flap. Br J Surg. 2011;98:880–4.CrossRefGoogle Scholar
  33. 33.
    Cimbanassi S, Lippi, M, Chiara O. Intensive care management of the open abdomen patient. In: Chiara O, Cimbanassi S, editors. Atlas of open abdomen in trauma-how I do it. Minerva Medica; 2017. p. 50–66.Google Scholar
  34. 34.
    Malbrain M, De Laet E. Intra-abdominal hypertension: evolving concepts. Clin Chest Med. 2009;30:45–70.CrossRefGoogle Scholar
  35. 35.
    Koehl R. Intra-abdominal hypertension and abdominal compartment syndrome. Crit Care Nurse. 2012;32:19–32.CrossRefGoogle Scholar
  36. 36.
    De Waele JJ, De L, De Keulenaer B, et al. The effect of different reference transducer positions on intra-abdominal pressure measurement. A multicenter analysis. Intensive Care Med. 2008;34:1299–303.CrossRefGoogle Scholar
  37. 37.
    Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in intensive care unit. N Engl J Med. 2004;350:2247–56.CrossRefGoogle Scholar
  38. 38.
    Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100–55.CrossRefGoogle Scholar
  39. 39.
    Veigas PV, Callum J, Rizoli S, et al. A sustematic review on the rotational thromboelastometry (ROTEM®) values for the diagnosis of coagulopathy, prediction and guidance of blood transfusion and prediction of mortality in trauma patients. Scand J Trauma Resusc Emerg Med. 2016;24:114–28.CrossRefGoogle Scholar
  40. 40.
    Cortes-Puentes GA, Gard KE, Adams AB, et al. Value and limitations of transpulmonary pressure calculations during intra-abdominal hypertension. Crit Care Med. 2013;41:1632–7.CrossRefGoogle Scholar
  41. 41.
    Guerrero M, Cannizzo F, Falta E, et al. Prone ventilation in a United State Marine with acute respiratory distress syndrome and open abdominal injury. South Med J. 2009;102:637–9.CrossRefGoogle Scholar
  42. 42.
    Mehta S, Burry L, Martinez-Motta JC, et al. A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial. Crit Care Med. 2008;36:2092–9.CrossRefGoogle Scholar
  43. 43.
    Payen JF, Chanques G, Mantz J, et al. Current practices in sedation and analgesia for mechanical ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology. 2007;107:858–60.CrossRefGoogle Scholar
  44. 44.
    Memis D, Inal MT, Kavalci G, et al. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25:458–62.CrossRefGoogle Scholar
  45. 45.
    Barr J, Fraser GL, Puntillo KL, et al. Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.CrossRefGoogle Scholar
  46. 46.
    Girard TD, Pandharipande PP, Carson SS, et al. Feasibility, efficacy, and safety of antipsychotic for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38:428–37.CrossRefGoogle Scholar
  47. 47.
    Cheatham ML, Safsak K, Brzezinski SJ, et al. Nitrogen balance, protein loss and the open abdomen. Crit Care Med. 2007;35:127–31.CrossRefGoogle Scholar
  48. 48.
    Majercik S, Kinikini M, White T. Enteroatmospheric fistula: from soup to n uts. Nutr Clin Pract. 2012;27:507–12.CrossRefGoogle Scholar
  49. 49.
    Dutton WD, Diaz JJ Jr, Miller RS. Critical care issues in managing complex open abdominal wound. J Intensive Care Med. 2012;27:161–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Trauma Team and Emergency Surgery, Niguarda Trauma CenterAAST Grande Ospedale Metropolitano NiguardaMilanItaly

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