The role of open abdomen in non-trauma patient: WSES Consensus Paper
Coccolini et al. World Journal of Emergency Surgery
The role of open abdomen in non-trauma patient: WSES Consensus Paper
Federico Coccolini 0
Giulia Montori 0
Marco Ceresoli 0
Fausto Catena 21
Ernest E. Moore 20
Rao Ivatury 29
Walter Biffl 27
Andrew Peitzman 25
Raul Coimbra 24
Sandro Rizoli 31
Yoram Kluger 30
Fikri M. Abu-Zidan 22
Massimo Sartelli 8
Marc De Moya 9
George Velmahos 9
Gustavo Pereira Fraga 6
Bruno M. Pereira 6
Ari Leppaniemi 7
Marja A. Boermeester 4
Andrew W. Kirkpatrick 5
Ron Maier 2
Miklosh Bala 3
Boris Sakakushev 1
Vladimir Khokha 11
Manu Malbrain 10
Vanni Agnoletti 12
Ignacio Martin-Loeches 13
Michael Sugrue 14
Salomone Di Saverio 15
Ewen Griffiths 16
Kjetil Soreide 17 18
John E. Mazuski 19
Addison K. May 23
Philippe Montravers 28
Rita Maria Melotti 26
Michele Pisano 0
Francesco Salvetti 0
Tino M. Valetti
Jeffry L. Kashuk
Luca Ansaloni 0
0 General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital , Piazza OMS 1, 24127 Bergamo , Italy
1 First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv , Plovdiv , Bulgaria
2 Department of Surgery, Harborview Medical Centre , Seattle 98104 , USA
3 General Surgery Department, Hadassah Medical Centre , Jerusalem , Israel
4 Academic Medical Center Amsterdam , Amsterdam , The Netherlands
5 Department of Surgery, Foothills Medical Centre , Calgary , Canada
6 Faculdade de Ciências Médicas (FCM) - Unicamp Campinas , São Paulo , Brazil
7 Second Department of Surgery, Meilahti Hospital , Helsinki , Finland
8 Department of Surgery, Macerata Hospital , Macerata , Italy
9 Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital , Boston, MA 02114 , USA
10 ICU and High Care Burn Unit , Ziekenhius Netwerk Antwerpen, Antwerpen , Belgium
11 General Surgery, Mozir Hospital , Mozir City , Belarus
12 ICU Department, Bufalini Hospital , Cesena , Italy
13 Critical Care Centre , Corporasiò Sanitaria Park Tauli, Sabdel , Spain
14 General Surgery Department, Letterkenny Hospital , Letterkenny , Ireland
15 General and Trauma Surgery Department, Maggiore Hospital , Bologna , Italy
16 Upper Gatrointestinal Surgery, Birmigham Hospital , Birmigham , UK
17 Department of Gastrointestinal Surgery, Stavanger University Hospital , Stavanger , Norway
18 Department of Clinical Medicine, University of Bergen , Bergen , Norway
19 Department of Surgery, School of Medicine, Washington University , Saint Louis, MO 63130 , USA
20 Denver Health , Denver, CO 80204 , USA
21 Emergency and Trauma Surgery, Parma Maggiore hospital , Parma , Italy
22 Department of Surgery, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
23 Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, TN 37232 , USA
24 Department of Surgery, UC San Diego Health System , San Diego 92103 , USA
25 Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine , Pittsburgh 15213 , USA
26 ICU department
27 Acute Care Surgery, The Queen's Medical Center , Honolulu, HI 96813 , USA
28 Département d'Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot , Paris , France
29 Trauma Surgery, Virginia Commonwealth University , Richmond, VA 23284 , USA
30 Division of General Surgery Rambam Health Care Campus , Haifa , Israel
31 Trauma & Acute Care Service, St Michael's Hospital , Toronto, ON , Canada
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
Open abdomen; Laparostomy; Non-trauma; Peritonitis; Pancreatitis; Vascular emergencies; Fistula; Nutrition; Re-exploration; Re-intervention; Closure; Biological; Synthetic; Mesh; Technique; Timing
The decision by a surgeon to utilize the open abdomen
(OA) technique is a dramatically non-anatomic situation
that dramatically increases resource utilization and has
potential severe side effects. It is, however, often
dramatically effective at countering the drastically impaired
physiology of critical illness when no other perceived
options exist. There are both mandatory and relative
indications for OA use, which are heavily influenced by
the primary pathophysiologic insults and responses to
intra-abdominal sepsis and inflammation, both inherent
to the patient and induced through medical treatments.
The abdominal compartment is dramatically affected in
both its contents and the characteristics of the
abdominal wall. Several factors as systemic inflammatory
response syndrome, increased vascular permeability, and
aggressive crystalloid resuscitation predispose to fluid
sequestration leading to peritoneal fluid formation.
Patients with severe sepsis and septic shock commonly
receive large amounts of resuscitation fluids and may
develop excessive gut edema and diminished
contractility and motility. These changes in combination with
sequestration of second and third space fluids and
forced closure of an abdominal wall with altered
compliance may result in increased intra-abdominal
pressure (IAP) ultimately leading to intra-abdominal
hypertension (IAH) or even abdominal compartment
syndrome (ACS) [
The pathophysiologic implications of elevated IAP
have been restarted to be studied in deep during the last
20 years [
]. In 2013, The Abdominal Compartment
Society (WSACS) updated the previously published
definition and guidelines for the management of
intraabdominal hypertension [
]. Elevated IAP constitutes
IAH and was classified into four grades: (1) grade I
IAP 12–15 mmHg, (2) grade II IAP 16–20 mmHg,
(3) grade III IAP 21–25 mmHg, and (4) grade IV IAP
>25 mmHg. Elevated IAP commonly causes marked
deficits in loco-regional and whole body perfusion
that may result in organ failure [
]. An uncontrolled
IAH, with an IAP exceeding 20 mmHg and new onset
organ failure, is defined as an abdominal
compartment syndrome (ACS) [
]. ACS is a syndrome and
not a disease, as such, it can have many causes and it
can occur in many disease processes, it is an all or
nothing phenomenon, while IAH is a more graded
continuum. ACS in turn has further effects on
intraabdominal organs, as well as indirect effects on the
other organ(s) and system(s). The ACS is a potentially
and frequently lethal complication characterized by
effects on splanchnic, cardiovascular, pulmonary,
renal, and central nervous systems [
medical therapies should be attempted, the ACS is
rapidly lethal and opening of the abdominal cavity
conducted promptly if medical interventions do not
quickly alleviate or temporize the situation. If surgery
has been undertaken for the index disease, leaving the
abdomen temporarily open is often required to prevent
inducing ACS in a critically ill pro-inflammatory patient
with visceral edema and ongoing resuscitation. Whether
leaving the abdomen open will primarily influence the
septic response is also intriguing but unproven at the
The OA procedure is defined as intentionally leaving
the fascial edges of the abdomen un-approximated
(laparostomy). The abdominal contents are exposed and
thus must be protected with a temporary coverage,
which is itself termed a temporary abdominal coverage
]. The OA technique, when used
appropriately, may be useful in the management of surgical
patients with compromised general conditions due to
any critical illness/injury but most frequently cases of
intra-abdominal sepsis and severe pancreatitis are seen
recently . Despite many serious potential
complications, the OA is perceived to be a life-saving
intervention in catastrophically injured patients [
to trauma patients, however, patients undergoing OA
management for intra-abdominal non-trauma
emergencies have greater risks subsequent to OA utilization,
including entero-atmospheric fistula (EAF) and a “frozen
abdomen”, intra-abdominal abscesses, and lower rates of
definitive fascial closure [
] with resultant large ventral
hernia defects. This discrepancy in risks and benefits,
along with economic considerations , was the primary
reason the WSACS suggested not routinely using the OA
for septic cases versus traumatic cases [
]. Thus, every
effort should be exerted to attempt abdominal closure as
soon as the patient can physiologically tolerate it.
The recommendations are formulated and graded
according to the modified Grading of Recommendations
Assessment, Development and Evaluation (GRADE) hierarchy of
evidence from the GRADE Group, summarized in the
Table 1 [
The WSES and Abdominal Compartment Society
together with the Donegal Research Academy united a
group of subject-matter experts coordinated by a central
coordinator to review and summarize the evidence and
thereafter to express their evidence-based opinion on
important issues concerning OA utilization in
Which non-trauma patients can benefit from OA
techniques and for which specific critical conditions
is indicated (example, peritonitis, vascular
emergencies, and severe pancreatitis)?
What is the optimum TAC technique for use in
Is there a role for fluid instillation?
What is the optimum timing of re-exploration before
definitive closure in non-trauma patients?
What is the optimum timing to definitively close an
OA in non-trauma patients?
What are the optimum adjunctive techniques to
definitively close an OA in non-trauma patients considering
both non-mesh-mediated techniques and mesh-mediated
What is the optimum treatment to treat frozen abdomen
and enteral fistulas?
What nutritional support is indicated in OA?
A central project coordinator compiled the answers and
statements derived from the first round of presentations
and discussions. The statements were discussed during
the Consensus Conference held in Dublin (Ireland) in July
2016. Once an agreement was reached within the experts
groups, a final round of discussion among a larger group
of experts led to the final version of
recommendations reflecting the final expert-consensus document
Open abdomen in peritonitis
The open abdomen is an option for emergency surgery
patients with severe peritonitis and septic shock under
the following circumstances: abbreviated laparotomy due
to the severe physiological derangement, or the need for a
deferred intestinal anastomosis or a planned second look
for intestinal ischemia, or persistent source of peritonitis
(failure of source control), or extensive visceral edema
with the concern for development of abdominal
compartment syndrome (grade 2C).
In severe secondary peritonitis, some patients may
experience a disease progression to severe sepsis and septic
shock experiencing progressive organ dysfunction,
hypotension, myocardial depression, and coagulopathy
and a staged approach may be required [
]. These are
often hemodynamically unstable and unfit for immediate
complex surgical interventions [
]. If the patient is not
in a condition to be undergone to a definitive repair
and/or abdominal wall closure, the intervention should
be abbreviated due to suboptimal local conditions for
healing and global susceptibility to spiraling organ
failure. For instance, intestinal continuity restoration can be
deferred to a subsequent surgical intervention, which is
particularly important in hypotensive patients who are
receiving inotropes [
]. In facing the impossibility to
completely obtain a source control of the contamination
in a single operation or if extensive visceral edema and
decreased abdominal wall compliance increases the risk
of ACS development, primary fascial closure should not
be attempted and the abdomen should be left open [
The rationale for using the OA is to leave the abdomen
open and to treat the infected peritoneal cavity like an
“open abscess” with subsequent re-operations involving
generous irrigations and potentially active TAC techniques
] to definitively control the contamination while also
preventing IAH progression to ACS. No definitive data
exist about the management of severe peritonitis with the
open abdomen. Robledo et al. compared open versus
closed abdomen procedures in 40 patients with severe
secondary peritonitis; no significant differences in mortality
rates were found (55% open vs. 30% closed). The study
was interrupted at the first interim analysis for high
relative risk and odds ratios for death in the open group (1.83
and 2.85, respectively) [
]. However, the TAC technique
that was selected as the “intervention” would be relatively
contraindicated in current OA management. Some other
The open abdomen is an option for emergency surgery patients with severe peritonitis and septic
shock under the following circumstances: abbreviated laparotomy due to the severe physiological
derangement, or the need for a deferred intestinal anastomosis or a planned second look for
intestinal ischemia, or persistent source of peritonitis (failure of source control), or extensive visceral
edema with the concern for development of abdominal compartment syndrome (Grade 2C).
The open abdomen should be strongly considered following management of hemorrhagic vascular
catastrophes such as ruptured abdominal aortic aneurysm (Grade 1C)
The open abdomen should be considered following surgical management of acute mesenteric
ischemic insults (Grade 2C).
In patients with severe acute pancreatitis unresponsive to step-up conservative management surgical
decompression and leaving the abdomen open is effective in treating abdominal compartment
syndrome (Grade 2C)
Leaving the abdomen open after surgical necrosectomy for infected pancreatic necrosis is not
recommended excepted in those situation at high risk of abdominal compartment syndrome (Grade 1C)
Negative pressure wound therapy with continuous fascial traction is suggested as the preferred
technique for temporary abdominal closure (Grade 1B).
Temporary Abdominal Closure without Negative pressure wound therapy (e.g., mesh alone, Bogota
bag) whenever possible should NOT be applied for the purpose of temporary abdominal closure,
because of low delayed fascial closure rate and being accompanied by a significant intestinal fistula
rate (Grade 1B).
There is inadequate evidence to make a recommendation regarding use of negative pressure wound
therapy in combination with fluid instillation in patients with temporary abdominal closure (NOT
- In critically ill non-trauma patients with open abdomen, once any requirements for on-going
resuscitation have ameliorated, early re-operation with the intention of closing the abdomen should
be given a high priority (Grade 1C).
- In critically ill patients with open abdomen, re-laparotomy with concern for ongoing ischemia/
contamination reoperation should be conducted no later than 24–48 h after the index operation,
with the duration from the index operation shortening with increasing degrees of patient
nonimprovement and hemodynamic instability (Grade 1C).
- Fascia should be closed as soon as possible (Grade 1C).
- Acidosis (pH <7.25), hypothermia (temperature < 34 °C) and coagulopathy (TEG, INR) are not
predictive of the need for maintaining the open abdomen in non-trauma patients (Grade 2A).
- The abdomen should be maintained open in non-trauma patients if the source of contamination
persists, if a condition of haemodynamic instability persists meaning in presence of on-going fluid
resuscitation or vasopressor support necessity, if a deferred intestinal anastomosis is needed, if there
is the necessity for a planned second look for ischemic intestine and lastly if there are concerns
about abdominal compartment syndrome development (Grade 2C).
- Early fascia closure (within 7 days) should be the strategy for management of the open abdomen
once the source control has been reached, the severe sepsis has been controlled meaning that the
patient is haemodynamically stable and the hypoperfusion has been definitively corrected, no
further surgical re-exploration is needed and there are no concerns for abdominal compartment
syndrome (Grade 2C).
- Primary fascia closure is the ideal solution to restore the abdominal closure (2A).
- Component separation is an effective technique; however, it’s early use is NOT recommended in
fascial temporary closure. It should be considered only for definitive closure or reconstructive
interventions (Grade 2C)
- Planned ventral hernia (skin graft or skin closure only) remains an option for complicated open
abdomen (i.e. in the presence of entero-atmospheric fistula or in cases with a protracted open
abdomen due to underlying diseases) or in those low resource setting where no other facilities are
present (Grade 2C)
- A fascial bridge using prosthetic mesh (polypropylene, polytetrafluoruroethylene (PTFE) and
polyester products) should NOTt be recommended to achieve definitive fascial closure in patients
with open abdomen and should be placed only in patients without other alternatives (Grade 1B).
- Biologic meshes are reliable for definitive abdominal wall reconstruction in the presence of a large
wall defect, bacterial contamination, comorbidities and difficult wound healing. NPWT can be used
combined with biologic mesh to facilitate granulation and skin closure (Grade 2B).
- Non–cross-linked biologic meshes seem to be preferred in sublay position when the linea alba can
be reconstructed. Non–cross-linked biologic mesh is easily integrated, with reduced fibrotic reaction
and lesser infection and removal rate (Grade 2B).
Best solution to definitively close an open abdomen
➢ Non-mesh mediated techniques
➢ Mesh mediated techniques
- The long-term outcome of a bridging non–cross-linked biologic mesh is laxity of the abdominal wall
and a high rate of recurrent ventral hernia. In the bridge position (no linea alba closure), cross-linked
biologic meshes maybe associated with less ventral hernia recurrence (Grade 2B).
- Several clinical circumstances may contribute to the development of entero-atmospheric fistula and
few risk factors may predict its development. Awareness of this complication and avoidance of
contributing conditions for its development are mandatory; moreover preemptive measures are
imperative (Grade 1C).
- The management of entero-atmospheric fistula should be personalized according to standard
classification and grading system. Current different classification schemes echo the problematic and
challenging issues related to their management (Grade 1C)
- The caloric intake and protein demands of patients with entero-atmospheric fistula increase; the
Nitrogen balance should be corrected and protein supplemented. Nutrition should be started
immediately upon recognition of entero-atmospheric fistula (Grade 1C)
- Entero-atmospheric fistula effluent isolation is essential for proper wound healing. Separating the
wound into different compartments in order to facilitate the collection of fistula output is of
paramount importance (Grade 2A).
- Many methods for wound care exist; however in the presence of entero-atmospheric fistula in open
abdomen, negative pressure wound therapy makes effluent isolation feasible and wound healing
conceivable (Grade 2A).
Definitive management of entero-atmospheric fistula should be delayed to after the patient has
recovered and the wound completely healed (Grade 1C).
- Open abdomen patients are in a hyper-metabolic condition; an immediate and adequate nutritional
support is mandatory (Grade 1C).
- Open abdomen techniques result in a significant nitrogen loss that must be replaced with a
balanced nutrition regimen (Grade 1C).
- Early enteral nutrition should be started as soon as possible if the gastrointestinal tract allows (Grade 1C).
- Enteral nutrition should be delayed in patients with high output fistula with no possibility to obtain
feeding access distal to the fistula (Grade 2C)
- Oral feeding is not contraindicated; whenever it’s possible it could be started as soon as the patient
is able to eat (Grade 2C).
- To date, no recommendations can be made about early mobilization of patients with open abdomen.
cohort studies showed the effectiveness of OA technique
in treating severe peritonitis. At present, however, no
definitive data from randomized trials exist.
Open abdomen in vascular emergencies
The open abdomen should be strongly considered
following management of hemorrhagic vascular catastrophes
such as ruptured abdominal aortic aneurysm (grade 1C).
The open abdomen should be considered following
surgical management of acute mesenteric ischemic insults
The ACS has been well described in the setting of
ruptured abdominal aortic aneurysm (rAAA) [
Rupture of aortic as well as iliac or visceral aneurysm
often results in life-threatening hemorrhagic shock.
The combination of severe shock and massive
resuscitation contributes to retroperitoneal, mesenteric, and
bowel wall edema and production of ascites that can
increase abdominal pressure and lead to ACS.
Intraabdominal hypertension occurs in up to 50% of
patients following AAA repair, and ACS occurs in 8–20%.
Mortality after rAAA is as high as 30–50%; of note,
mortality is generally twice as high among patients who
develop ACS compared with those who do not [
Consequently, prevention of ACS, if possible, would
be of tremendous benefit to the patient.
In prospective non-randomized studies, the incidence
of ACS is reduced when prophylactic OA is employed
]. Unfortunately, selection criteria for employing OA
are not well defined; the surgeon might consider
inability to close the fascia without tension; use of
aortic balloon occlusion catheter; and preoperative
blood loss >5 L [
]. Such criteria should prompt
the surgeon to consider temporary OA utilization. When
the abdomen is closed primarily, postoperative monitoring
of IAP is recommended, with vigilance for ACS as
reflected by elevated airway pressures, reduced cardiac
output, or oliguria. Concerns for infection of aortic grafts
with OA are allayed by existing data, indicating a relatively
low rate . Patients are often selected for endovascular
repair (EVAR) of rAAA if they have less hemodynamic
compromise. Although it is less common, ACS still occurs
after EVAR [
]. The major risk factor appears to be
massive resuscitation. These patients should have vigilant
monitoring for elevated IAP and the onset of ACS.
Mesenteric ischemia may result from arterial
(thrombotic, embolic, or low perfusion) or venous (venous
thrombosis) insults. Fundamental principles of
management include making the diagnosis, restoration of
intestinal perfusion, and assessment of bowel viability with
resection as necessary. The bowel ischemia leads to
bowel wall and mesenteric edema, as well as ascites
production; reperfusion of the bowel can exacerbate
bowel edema and ascites and thus increase risk of ACS.
For this reason, OA use should be considered following
restoration of perfusion in a patient with acute
mesenteric ischemia. As there are no reliable independent
predictors of ACS in this setting, the surgeon should
assess bowel swelling and the patient’s physiology to make
this decision [
]. Another reason to consider
temporary OA following mesenteric ischemia is to facilitate
second-look laparotomy to assess bowel viability and
perform bowel anastomosis as needed . Bowel
resection is much less common in the setting of venous
thrombosis than arterial occlusion, so the patients with
mesenteric venous thrombosis probably do not require
OA as often as those with acute arterial occlusion [
although, IAP should be followed.
Open abdomen in pancreatitis
In patients with severe acute pancreatitis unresponsive to
step-up conservative management, surgical decompression
and leaving the abdomen open is effective in treating
abdominal compartment syndrome (grade 2C).
Leaving the abdomen open after surgical necrosectomy
for infected pancreatic necrosis is not recommended
except in those situations at high risk of abdominal
compartment syndrome (grade 1C).
Acute pancreatitis (AP) is a mild self-limiting disease
in the majority of cases, even though the 15% of patients
with AP progress to severe disease identified by
development of persistent organ failure [
]. Multiple organ
failure (MOF) is the factor mainly associated to mortality in
AP, as a counterpart in absence of organ dysfunction or
if it transient the risk of dying is very low [
However, in those with severe AP, MOF develops generally
early, with over half of the patients exhibiting organ
dysfunction’s signs at hospital admission and in any case,
most part of them develops within the first 4 days after
]. More than half of the deaths happen
within the first week from onset of AP and generally within
a week after MOF first symptoms . Principal treatments
of MOF are support therapies: vasopressors, fluid
replacement, and renal replacement therapy and mechanical
ventilation if indicated. During AP, IAH/ACS may aggravate
MOF, and therefore, constant IAP measurements are
crucial to identify patients with high risk of developing ACS
]. ACS should be prevented and treated, whenever
possible, with non-operative management. Surgical
decompression is the last but the most effective tool to decrease
the IAP, and it should not be postponed if the patient
presents ACS manifestation [
In the event of AP, the risk to develop subsequent
infections (i.e., bacteremia, pneumonia and infection of
pancreatic or peripancreatic necrosis) is increased. The first week
of illness is crucial for the extra-pancreatic infection
occurrence, whereas pancreatic necrosis usually becomes
infected later [
]. Some factors are associated to an
increased risk of infected necrosis: the presence of organ
failure, early bacteremia, and the extent of pancreatic
]. Surgical necrosectomy is the last resort if more
conservative management including percutaneous
drainage failure [
]. Patients with persistent organ failure
complicated with infected pancreatic necrosis face a very high
mortality risk [
Optimal technique for temporary abdominal closure
Negative pressure wound therapy with continuous fascial
traction is suggested as the preferred technique for
temporary abdominal closure (grade 1B).
Temporary abdominal closure without negative
pressure wound therapy (e.g., mesh alone, Bogota bag)
whenever possible should NOT be applied for the purpose of
temporary abdominal closure, because of low delayed
fascial closure rate and being accompanied by a
significant intestinal fistula rate (grade 1B).
There is inadequate evidence to make a
recommendation regarding use of negative pressure wound therapy in
combination with fluid instillation in patients with
temporary abdominal closure (NOT GRADED).
The perceived indications and subsequent treatment
choices in managing OA differ among surgeons. The
existing techniques result in different risk of
enteroatmospheric fistula (EAF) and the different rate of delayed
fascial closure. Overall, 74 relevant studies exist for a total
of 4358 patients: 3461 (79%) with peritonitis. The
described OA indications are considerably different.
Thirtyeight out of 78 series described negative pressure wound
therapy (NPWT) TAC systems. NPWT with a dynamic
component (mesh-mediated fascial traction or dynamic
sutures) gives the best results in terms of delayed fascial
closure, but dynamic sutures result more often in fistula.
NPWT without a dynamic component (Barker’s VAC or
commercial products) for the use of temporary fascial
closure has a moderate delayed fascial closure rate and a
fistula rate similar to mesh closure without NPWT.
Several TAC techniques exist that could be used
alone or combined together. Six-eight series reported
about one TAC technique. Ten series described
patients managed with combined TAC systems. NPWT
was used alone in 32 studies [
], and in 6
studies, NWPT is combined with fascial traction (mesh or
] and eight series described the use of
meshes (non-absorbable and/or absorbable) [
Six series reported about the Bogota-bag use [
five, about Zipper [
]; and other five, about dynamic
retention sutures [
]. Two more series described
loose packing [
]. Lastly, the Wittmann patch was
used in one series [
]. The remnant three series applied
different TAC systems [
82, 100, 101
]. The delayed fascial
closure rate ranged from 3.2 to 100%.
Twenty-two series were prospective, and ten out of
them described NPWT (608 patients) showing a
weighted fascial closure rate of 53.9% and an EAF rate
of 9.8%. The four prospective series on NPWT with
fascial traction (411 patients) showed a weighted fascial
closure rate of 77.8% and an EAF rate of 4.3%. Including
retrospective studies data per closure type are in line
with the aforementioned results. With the highest
weighted fascial closure rate for NPWT with fascial
traction (73.1%) and dynamic retention sutures (73.6%).
TAC using a mesh or zipper showed the lowest delayed
closure rates (34.2 and 34.0% respectively). Nine series
were not exhaustive in describing eventual fascial
closure attempts [
16, 45, 75, 81, 87, 89, 98, 102, 103
Is there a role for NPWT with fluid instillation?
There are no series published on the use of NPWT with
instillation in situations of TAC in non-trauma patients
or in trauma patients. Recently, a systematic review
performed by an expert consensus group has been
published underlining the need of more evidence to support
the fluid instillation and giving no recommendation of
its use in abdominal wound [
Planning re-exploration before definitive closure
In critically ill non-trauma patients with open abdomen,
once any requirements for on-going resuscitation have
ameliorated, early re-operation with the intention of closing the
abdomen should be given a high priority (grade 1C).
In critically ill patients with open abdomen, re-laparotomy
with concern for ongoing ischemia/contamination
reoperation should be conducted no later than 24–48 h after
the index operation, with the duration from the index
operation shortening with increasing degrees of patient
nonimprovement and hemodynamic instability (grade 1C).
A related question for clinicians is when to re-operate
(if ever) for the sole purpose of “revise” when there is
recognition that closing an abdomen will not be possible.
This question may be further conceptually complicated in
an attempt to distinguish indications to re-operate
because the patient is not improving or deteriorating and
there is fear that contamination or ischemia is ongoing
and those cases of non-improvement or only modest
improvement in whom there is operation intention to “wash”
the peritoneal cavity and to “change” the TAC dressing or
device. No RCTs or meta-analyses examining the timing
of re-operation in OA patients exist. Guidelines and
review papers did not generally discuss timing of
]. In the position paper of the WSES, it is
recommended that as a general principle, patients should
be taken back to the operating room at 24–48 h after the
initial surgery . Other expert opinions come from the
survey of Trauma Association of Canada in 2006, and the
majority of responders indicated the best timing included
between 24 and 72 h [
]. Pommerening et al.
utilized the American Association for the Surgery of Trauma
(AAST) Open Abdomen Registry to evaluate time to the
first re-operation on trauma OA patients as a predictor of
primary fascial closure using a hierarchical multivariate
logistic regression analysis . Adjusting for other factors,
including resuscitation volumes, increasing delay to the
first re-operation was associated with a decreased
likelihood of primary fascial closure (PFC), with a 1.1%
decrease in PFC rates for every hour after 24 h from the
index operation [
]. Further, there was a trend (95% CI
1.0–3.25 OR) of increased complications in patients
having the first re-operation after 48 h [
It should be clearly understood however that
extrapolation of these findings regarding the timing of
re-operation in trauma patients might not be directly
applicable to non-trauma patients with OA. It is
becoming apparent that infected and non-infected
patients with auto-activation of the immune responses
leading to multi-organ dysfunction syndrome (MODS)
and MOF have more fundamental differences than
previously appreciated [
]. Fundamental evidences from
basic science are emerging justifying the OA in critically
ill/injured patents in order to manipulate the systemic
immune response and ameliorate the bio mediator burdens
of catastrophic illness [
]. There are also newly
described populations of fully mature indwelling peritoneal
macrophages that migrate locally within the peritoneal
cavity within an hour of injury . Whether
mechanically removing such cell populations through scheduled
“wash-outs” is beneficial or harmful is a completely
unstudied question. Thus, the timing of re-operation is more
complex in non-trauma patients and urgently requires
further study. Lastly, in critically ill patients with an OA,
re-laparotomy with the intention of cleaning or
“washingout” the abdomen has an unknown priority and should be
subjected to future randomized study.
Best timing to definitively close an open abdomen
Fascia should be closed as soon as possible (grade 1C).
Acidosis (pH <7.25), hypothermia (temperature <34 °C),
and coagulopathy (TEG, INR) are not predictive of the
need for maintaining the open abdomen in non-trauma
patients (grade 2A).
The abdomen should be maintained open in
nontrauma patients if the source of contamination persists, if
a condition of hemodynamic instability persists meaning
in the presence of an on-going fluid resuscitation or
vasopressor support necessity, if a deferred intestinal
anastomosis is needed, if there is the necessity for a planned
second look for ischemic intestine, and lastly if there are
concerns about abdominal compartment syndrome
development (grade 2C).
Early fascia closure (within 7 days) should be the
strategy for management of the open abdomen once the source
control has been reached, the severe sepsis has been
controlled meaning that the patient is hemodynamically
stable and the hypoperfusion has been definitively
corrected, no further surgical re-exploration is needed, and
there are no concerns for abdominal compartment
syndrome (grade 2C).
The early definitive abdominal closure is the first goal
to achieve in order to reduce the OA complications rate
], (i.e., EAF, fascial retraction with loss of abdominal
wall domain, and incisional hernias) [
primary closure rates have a bimodal distribution, with
early closure depending on postoperative intensive care
management and delayed closure depending on the
choice of the TAC technique . Mortality,
complications, and length of stay were compared between early
and delayed fascial closure in a meta-analysis [
patients were included and 1942 (62%) successfully
achieved early fascial closure. Early fascial closure is a
factor significantly associated with a reduced mortality
(12.3 versus 24.8%, RR 0.53, P < 0.0001) and
complication rate (RR, 0.68, P < 0.0001). Early fascial closure is
commonly performed within 4–7 days of the initial
]. No major technical difficulties are
described to obtain primary fascial closure within few days
from the index operation. Patients having abdominal
sepsis are less likely to achieve an early fascial closure
] and therefore should have closure attempts
performed as soon as possible after severe abdominal sepsis
is controlled [
Best solution to definitively close an open abdomen
Often the OA, particularly if prolonged, results in
fascia retraction and consequently in large abdominal
wall defects that require complex abdominal wall
reconstruction. Moreover, the situation is often
complicated by a contaminated field [
] with high risk of
infections and wound complications, such as wound
infections, seromas, fistula formation, recurrence of
the defect, and mortality [
Primary fascia closure is the ideal solution to restore the
abdominal closure (grade 2A).
Component separation is an effective technique; however,
its early use is NOT recommended in fascial temporary
closure. It should be considered only for definitive closure
or reconstructive interventions (grade 2C).
Planned ventral hernia (skin graft or skin closure only)
remains an option for complicated open abdomen (i.e., in
the presence of entero-atmospheric fistula or in cases with
a protracted open abdomen due to underlying diseases) or
in those low-resource setting where no other facilities are
present (grade 2C).
Abdominal component separation is most commonly
considered an elective procedure for ventral hernia
]. One important technique described for the
reconstruction of the abdominal wall is the component
separation. The technique of anterior component
separation consists in a relaxing incision made in the
aponeurosis of the external oblique muscle, a separation of
the external and internal oblique muscle and the incision
of the rectus fascia to achieve the advancement of the
abdominal wall to cover the defect. This technique has
been well studied and described in elective giant ventral
hernia repair, and it provides an effective technique with
a recurrence rate of 16% [
] but a very relevant
complication rate of 50%. Other surgical techniques that
have been described include the posterior component
separation: the rectus sheath is opened and the posterior
rectus fascia and rectus muscle are separated. At the
lateral margin of the rectus muscle, the aponeurosis of
the transverse abdominis muscle is incised with the
separation of the internal oblique muscle from the
transverse abdominis muscle.
However, the use of abdominal component separation
technique was recently described in acute fascia closure
after open abdomen in a small case series by Rasilainen et
] with 75% of primary fascia closure. At present,
there is not enough evidence to support component
separation in the acute setting due to the related high
morbidity and the fact that these techniques can only be
performed on a patient once, so that if ill timed, future
options are not available. Therefore, a valuable alternative
option for closure of the open abdomen remains the
planned ventral hernia: its main goal is to cover abdominal
viscera to prevent complications such as EAF. The
abdominal wall defect could be closed only with skin suture
and or a skin graft put on the underlying granulating
tissue creating a planned laxity. After physiologic recovery
and a significant period of scar and adhesion maturation,
the complete restoration of the patient’s abdominal wall
through reconstructive techniques can be undertaken as
an elective procedure.
A fascial bridge using prosthetic mesh (polypropylene,
polytetrafluoruroethylene (PTFE) and polyester products) should
not be recommended to achieve definitive fascial closure in
patients with open abdomen and should be placed only in
patients without other alternatives (grade 1B).
Biologic meshes are reliable for definitive abdominal
wall reconstruction in the presence of a large wall defect,
bacterial contamination, comorbidities, and difficult
wound healing. NPWT can be used combined with
biologic mesh to facilitate granulation and skin closure
Non-cross-linked biologic meshes seem to be preferred in
sublay position when the linea alba can be reconstructed.
Non-cross-linked biologic mesh is easily integrated, with
reduced fibrotic reaction and lesser infection and removal
rate (grade 2B).
The long-term outcome of a bridging non-cross-linked
biologic mesh is laxity of the abdominal wall and a high
rate of recurrent ventral hernia. In the bridge position
(no linea alba closure), cross-linked biologic meshes
maybe associated with less ventral hernia recurrence
Two meta-analyses exist on BP in abdominal wall
defect. The first, by Sharrock et al. investigated the
management and closure of OA in trauma patients [
Among the included studies, the point estimate
recurrence rate of ventral hernia after 1 year of BP
positioning was 51%. However, the authors highlighted the
small number of included studies and their poor
quality; moreover, as above mentioned, great differences
exist between trauma and septic patients and great
caution should be addressed in interpretation of this result.
A systematic review and meta-analysis by Atema et al.
] investigated the utilization of BP in abdominal
wall reconstruction. They clearly stated that the poor
quantity and quality of available data strongly limits
taking a clear message from the results. Biological material
in infected fields had a recurrence rate of 30% compared
with 7% of synthetic material, but data were derived from
a single study and does not justify the use of synthetic
materials, especially as a bridge position after OA.
The “bridging” technique refers to using some mesh
(either prosthetic or biologic) to physically interpose between
native abdominal wall fascia that either cannot or should
not be primarily opposed. Thus, such fascial defects can
be closed with a mesh in a bridging position. In general,
non-absorbable synthetic materials (i.e., polypropylene
mesh) reinforce any fascial repair through a combination
of mechanical tension and intense inflammatory reaction,
resulting in the entrapment of the mesh into scar tissue.
However, in a bridging position, there is no native tissue
to protect viscera from the mesh and thus, the persistent
inflammatory response combined with the contaminated
field may induce local side effects such as adhesions,
erosions, and fistula formation [
guidelines on emergency repair of abdominal wall hernia
therefore do not recommend the use of synthetic meshes
in contaminated fields .
Biological prosthesis (BP) has been designed to perform
as permanent surgical prosthesis in the abdominal wall
repair, minimizing mesh-related complications [
rationale of their usage in OA is based on the premise that
the implantation of a biologic material triggers a cascade
of events leading to new healthy tissue deposition and
prosthesis remodeling. The presence of vital tissue
therefore allows for perfusion and a native immune response
preventing mesh infection and abscess formations. The
ideal BP will also maintain mechanical characteristics of a
synthetic mesh with a sufficient mechanical strength to
withstand the physiological and anatomic stresses of the
human abdominal wall. Such an ideal BP should also
tolerate adjunctive NPWT to facilitate wound healing,
granulation, and skin closure [
Discordant data have been published about the use of
BP to bridge a wide defect of the abdominal wall. The
evidence is limited with few studies, all non-randomized,
and with an overall small number of cases. Further
among heterogeneous patients reported, recurrence rates
have ranged between 0 and 100% [
]. When used
as a bridge to close the fascia defect, the reported
recurrence rate in a large retrospective series was >80% .
Another study by Booth and colleagues compared
primary fascia closure with mesh reinforcement with the
use of the mesh as a bridge and demonstrated a higher
recurrence rate in the mesh in a bridge position (8 vs.
56%, p < 0.001) [
Several studies investigated the best anatomical
position in terms of BP function, but were not specifically
focused on OA reconstruction. Nonetheless, evidence,
including that from randomized trials, suggest that
implanting the BP in the sublay position results in a
lower recurrence and complication rate [
However, it should be stressed that the data included
was not specific for the OA situation and the
heterogeneity among patients and indications was very high,
resulting in a poor level of evidence.
Two meta-analyses exist on BP in abdominal wall
defect. The first, by Sharrock et al. investigated the
management and closure of OA in trauma patients [
the included studies, the point estimate recurrence rate of
ventral hernia after 1 year of BP positioning was 51%.
However, the authors highlighted the small number of
included studies and their poor quality; moreover, as above
mentioned, great differences exists between trauma and
septic patients and great caution should be addressed in
interpretation of this result.
A systematic review and meta-analysis by Atema et
] investigated the utilization of BP in
abdominal wall reconstruction; the poor quantity and quality
of available data strongly limits the results. Biological
material in infected fields had a recurrence rate of
30% compared with 7% of synthetic material, but data
were derived from a single study and does not justify
the use of synthetic materials, especially as a bridge
position after OA.
In conclusion, no definitive evidence-based conclusions
could be obtained currently from the literature. The
available evidence is really weak: most of the cited
metaanalysis included rather poor quality retrospective case
series. There is also great heterogeneity among the
indications for mesh implantation, the anatomic positioning of
the mesh, and the type of mesh. This further weakens the
quality of the evidences. Thus, well-performed
randomized trials comparing different type of meshes and the
techniques of mesh positioning are urgently required.
Best treatment for open abdomen and enteroatmospheric fistulas
Several clinical circumstances may contribute to the
development of entero-atmospheric fistula and few risk
factors may predict its development. Awareness of this
complication and avoidance of contributing conditions
for its development are mandatory; moreover, preemptive
measures are imperative (grade 1C).
The management of entero-atmospheric fistula should
be personalized according to standard classification and
grading system. Current different classification schemes
echo the problematic and challenging issues related to
their management (grade 1C).
The caloric intake and protein demands of patients
with entero-atmospheric fistula increase; the nitrogen
balance should be corrected and protein supplemented.
Nutrition should be started immediately upon
recognition of entero-atmospheric fistula (grade 1C).
Entero-atmospheric fistula effluent isolation is essential
for proper wound healing. Separating the wound into
different compartments in order to facilitate the collection of
fistula output is of paramount importance (grade 2A).
Many methods for wound care exist; however, in the
presence of entero-atmospheric fistula in an open
abdomen, negative pressure wound therapy makes effluent
isolation feasible and wound healing conceivable (grade 2A).
Definitive management of entero-atmospheric fistula
should be delayed to after the patient has recovered and
the wound completely healed (grade 1C).
Enteric fistula is a severe complication following
abdominal surgery. The opening of a fistula onto dehisced
wound therefore exposing and communicating the bowel
and its effluent to the atmosphere is defined as EAF.
The incidence of EAF varies from 4.5 to 25% in the
trauma setting [
] and from 5.7 and 17.2% in
nontrauma patients [
]. The presence of this complication
dramatically increases considerably mortality, length of
stays, and costs [
Many factors may contribute to the development of
EAF. All linked as a “vicious cycle”: the lack of overlying
soft tissue, with its blood supply, precludes spontaneous
healing and the exposed viscera predispose to additional
disruptions in the gastrointestinal tract. EAFs may result
from various etiologies: anastomotic dehiscence or
disruption, iatrogenic injury during dissection or
inappropriate handling, and presence of synthetic prosthetic
material (i.e., mesh) and from the prolonged exposure of
]. ACS and severe IAH may result in
reduced bowel blood supply and therefore contribute to
EAF development . A prospective analysis of 517
trauma emergency laparotomies showed that large bowel
resections, large volume fluid resuscitation (>5 L/24 h),
and increased number of re-explorations were
significantly associated with an increased incidence of EAF
]. Preemptive measures could be undertaken in
order to prevent this complication: early abdominal wall
closure, bowel coverage with omentum or skin, and no
direct application of NPWT on the viscera are some of
these measures [
112, 164, 165
Several classifications and grading systems of EAF
exist. Schein and Decker proposed in 1991 a grading
system based on the fistula location. Grade IV indicates a
fistula related to large abdominal wall defects with
grades IVa and IVb indicating the site of the fistula in
regards to its location [
]. EAF can be classified based
on the fistula effluent output: low (<200 ml/day),
moderate (200-500 ml/day), and high (>500 ml/day) [
Bjork et al. proposed a classification based on the
presence of adhesions of the bowel in the setup of the open
abdomen as well as the association to the fistula
formation (Fig. 1), and this was later adapted by WSACS
]. Di Saverio et al. proposed a comprehensive
classification based on the combination of different criteria as
anatomical location, output, exposure, and number of
]. As a general principle, a single, superficial
fistula located in the lower GI tract with a low output
has a higher probability of spontaneous closure rather
than multiple fistulas deep in the wound with high
]. According to this principle, the
management should be tailored to each clinical situation and
individualized accordingly. In conclusion, the presence
of several different classifications represents the true
difficulties in the management of EAF in OA. Level of
evidence is poor and many recommendations are based on
expert opinion suggestions.
EAF is a poorly predictable and, above all, avoidable
complication. When patients develop EAF, an accurate
and tailored management scheme should be adopted.
Nutrition plays a key role in the management of these
patients and should be always kept in mind as a
fundamental part of the treatment. The open abdomen
strategy may result in fluid and electrolytes loss resulting in
acid-base derangements [
]. The anatomy and the
characteristics of the EAF(s) should be defined in order to
plan the best treatment option [
nutrition (TPN) should be started immediately after the
patient resuscitation. Enteral nutrition in OA patients has
been well studied demonstrating a reduction in
infectious complications preserving the intestinal mucosal
barrier and its immunological function [
Enteral nutrition in patients with an EAF is has but may
increase fistula output. Only small series of patients
with EAF treated with EN exists; therefore, no strong
evidence can support these treatments and further
studies are needed [
]. The use of octreotide
analogs is controversial. No evidence exists about the use
of somatostatin and octreotide in managing of EAF.
Few studies suggest that octreotide may reduce fistula
output by diminishing GI secretions  while others
argue their benefit due to this agents’ reduction in
splanchnic blood flow and reduction in immune
The main goal in the management of EAF should be
the closure of the fistula. Differently from common GI
fistulas, the EAF is not a true fistula since a fistula tract
does not exist. The lack of surrounding tissues prevents
the spontaneous closure. The goal of the treatment
should be focused on trying to isolate the fistula effluent
and enhancing the formation of granulation tissues
surrounding it. Several different techniques were described
and proposed in the literature to control and treat EAF,
and some attempts to standardize its management exist
]. A patient diagnosed with EAF in the setup of
OA should be treated by medical personnel familiar with
this complication and its consequences.
Accurate fistula definition and anatomy should be made.
Sepsis control and management is important. Diversion of
the fistula output in order to maintain clean the peritoneal
cavity is mandatory. Fistula effluent should be measured
in order to facilitate fluid balance and to ensure skin
protection from its digestive nature on the skin. This will
enhance and allow better patient care and mobility.
Several different dressing and techniques were
described for the management of EAF, each one with
relatively small case series and discordant results with a
consequent poor level of evidence [
162, 170, 180–183
Proposed treatments vary from primary suture and fibrin
glue for small exposed distal fistula to a fistula
suspension fixating the fistula edges to the skin. Several
variants of NPWT with devices for fistula isolation and
diversion were described with promising outcomes.
The several techniques are described in detail
elsewhere and are not in the scope of the current position
]. The described method to manage NPWT in
patients with EAF in the setup of OA should be applied
depending on surgeon preference, skills, and expertise
and according to hospital facilities and material
availability. Generally, negative pressure wound therapy, with
specifically described variants, is the most accepted
technique. EAF isolation and proper wound management
will enable skin grafting and converting EAF to a more
controllable one with ease of applying effluent collection
bag. The definitive treatment, i.e., closure of the fistula
and repairing the abdominal wall defect should be
postponed at least 6 months and only after the patient and
the wound healed completely.
Open abdomen patients are in a hyper-metabolic
condition; an immediate and adequate nutritional support is
mandatory (grade 1C).
Open abdomen techniques result in a significant
nitrogen loss that must be replaced with a balanced nutrition
regimen (grade 1C).
Early enteral nutrition should be started as soon as
possible if the gastrointestinal tract allows (grade 1C).
Enteral nutrition should be delayed in patients with
high output fistula with no possibility to obtain feeding
access distal to the fistula (grade 2C).
Oral feeding is not contraindicated; whenever its
possible, it could be started as soon as the patient is
able to eat (grade 2C).
The hyper-catabolic state of critically ill patients is
associated with muscle proteolysis, acute protein malnutrition,
immune function impairment, and subclinical
development of MOF. Several studies clearly demonstrated
malnutrition as a fundamental risk factor associated to poor
outcomes during hospital stay [
]. Furthermore, in a
critically ill patient, OA leads to significant nitrogen loss
estimated to be 2 g per liter of abdominal fluid output.
This issue requires adequate consideration and an
adjusted integration [
]. For this reason, the measurement
of the abdominal fluid loss is mandatory [
]. This loss
in nitrogen and protein is ulterior greatly increased in the
presence of EAF. A particular attention must be given to
this critical aspect because patients with OA are the
sickest, most inflamed, and subsequently most
hypermetabolic among surgical patients. During the OA patient
management, once the resuscitation is almost completed
and the GI tract allows it, EN should be started as soon as
possible. Thus, it will bring beneficial effects for the
patient as faster fascia closure and lower pneumonia and
fistula rate [
173, 186, 187
]. If malnutrition occurs, mucosal
atrophy and malabsorption are among the earliest
consequences. Gut-associated lymphoid tissue seems to be
diminished, and as a consequence, it can increase the risk
for disseminated infection due to bacterial translocation
through the intestinal wall [
]. EN helps in maintaining
gut mucosal barrier in good shape and function; as a
consequence, it has been demonstrated to enhance immunity
and IgA secretion, to prevent muscle atrophy, and lastly
to decreases systemic inflammation and oxidative injury
]. Early EN within the first 24–48 h is
demonstrated to improve wound healing, decrease catabolism,
preserve GI tract integrity, and finally, it reduces
complications, length of hospital stay, and costs. Compared to
TPN early EN decreases septic complications especially in
abdominal trauma and traumatic brain injuries. A
retrospective, single-institution study comparing DCS
interventions with open abdomen performed to treat ACS, 43
patients underwent early (<4 days) and 35 late (>4 days)
EN. Early EN significantly increased primary closure (74%
vs. 49%), reduced the fistula rate (9% vs. 26%) with no
difference in infections and but with a significant
reductions in hospitalization costs .
To date, no recommendations can be made about early
mobilization of patients with open abdomen.
Patients with an open abdomen generally should not be
mobilized out of bed until their abdomens are definitively
closed, for risk of evisceration [
]. This statement was
extrapolated from trauma literature [
prolonged bed rest is associated with significant increase in
complication rate. More recent attention has been focused
on intensive care unit (ICU)-acquired weakness and the
long-term adverse functional sequelae for ICU survivors,
particularly in the physical domain and this has led to an
increased interest in early mobilization in the ICU as a
potential means of prevention [
]. The optimal
timing for initiation of mobilization of patients with OA
has yet to be defined. Early mobilization is currently
defined as occurring within the first 2 to 5 days of ICU
Patients with open abdomen managed with NPWT
however, may be mobilized by active or passive transfer.
Further research must occur to provide the rationale to
early mobilization prior to definitive abdominal closure.
Management of the open abdomen remains a very
controversial domain, in which many techniques are still
debated. Many important issues remain to be addressed
through carefully designed and rigorously conducted
studies. Until better data is available, the use of the OA should
be carefully tailored to each single patient taking care to
not overuse this effective tool. Every effort should be
exerted to attempt abdominal closure as soon as the patient
can physiologically tolerate it. Finally, all the precautions
should be considered to minimize the complication rate.
AAST: American Association for the Surgery of Trauma; ACS: Abdominal
compartment syndrome; AP: Acute pancreatitis; BP: Biological prosthesis;
EAF: Entero-atmospheric fistula; EN: Enteral nutrition; EVAR: Endovascular
repair; GRADE: Grading of Recommendations Assessment, Development and
Evaluation; IAH: Intra-abdominal hypertension; IAP: Intra-abdominal pressure;
INR: International Normalized Ratio; MODS: Multi-organ dysfunction
syndrome; MOF: Multiple organ failure; NPWT: Negative pressure wound
therapy; OA: Open abdomen procedure; PTFE: Polytetrafluoruroethylene;
rAAA: Ruptured abdominal aortic aneurysm; RCT: Randomized controlled
trial; TAC: Temporal abdominal closure; TEG: Thromboelastography;
TPN: Parenteral nutrition; WSACS: The Abdominal Compartment Syndrome;
WSES: World Society of Emergency Surgery
Special thanks to Ms. Franca Boschini (Bibliographer, Medical Library, Papa
Giovanni XXIII Hospital, Bergamo, Italy) for the precious bibliographical work.
FCo, GMo, MC, FCa, EEM, RI, WB, AP, RC, SR, YK, FMA-Z, MSa, MDM, GV, GPF,
BMP, AL, MAB, AK, RM, MB, BS, VK, MM, VA, MIL, MSu, SDS, EG, KS, JEM, AKM,
PM, RMM, MP, FS, GMa, TMV, TS, OC, JLK, and LA did the manuscript conception
and draft, critically revised the manuscript, and contributed with important
scientific knowledge giving the final approval. All authors read and approved
the final manuscript.
Sant’Orsola-Malpighi University Hospital, Bologna, Italy. 33ICU Department,
Papa Giovanni XXIII Hospital, Bergamo, Italy. 34Trauma Surgery department,
University of Maryland School of Medicine, Baltimore, MD 21201, USA.
35Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy.
36General Surgery department, Assuta Medical Centers, Tel Aviv, Israel.
Ethics approval and consent to participate
Consent for publication
Manu LNG Malbrain is Founding President and current Treasurer of the
Abdominal Compartment Society (WSACS, www.wsacs.org). He is also a
member of the executive committee of the International Fluid Academy
(IFA). The IFA is integrated within the not-for-profit charitable organization
iMERiT (International Medical Education and Research Initiative) under
Belgian Law. The IFA website (http://www.fluidacademy.org) is now an
official SMACC (Social Media and Critical Care) affiliated site, and its content
is based on the philosophy of FOAM (Free Open Access Medical
Education—#FOAMed). He is a member of the medical advisory board of Pulsion Medical
Systems (Maquet Getinge group) and consults for Acelity, ConvaTec,
Spiegelberg and Holtech Medical.
Andrew Kirkpatrick has consulted for the Innovative Trauma Corporative,
Acelity Corp., and Cook Medical Corp. The authors declare that they have no
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