REVIEW ARTICLE

Eastern Association for the Surgery of Trauma: A Review of the

Management of the Open Abdomen—Part 2 “Management of
the Open Abdomen”
Jose J. Diaz, Jr., MD, William D. Dutton, MD, Mickey M. Ott, MD, Daniel C. Cullinane, MD,
Reginald Alouidor, MD, Scott B. Armen, MD, Jaroslaw W. Bilanuik, MD, Bryan R. Collier, DO,
Oliver L. Gunter, MD, Randeep Jawa, MD, Rebecca Jerome, MS, Andrew J. Kerwin, MD, John P. Kirby, MD,
Anne L. Lambert, MD, William P. Riordan, MD, and Christopher D. Wohltmann, MD

D uring the course of the last 30 years, several authors have

contributed their clinical experience to the literature in
an effort to describe the various management strategies for
heterogeneous that clear recommendations could not be pro-
vided. What follows is a thorough review of the current
literature for the management of the open abdomen: part 2
the appropriate use of the open abdomen technique. There “Management of the Open Abdomen” and provides clinical
remains a great degree of heterogeneity in the patient popu- direction regarding the following specific topics.
lation, and the surgical techniques described. The open ab-
domen technique has been used in both military and civilian 1 Early and Delayed Abdominal Fascial Closure (DAFC).
2. Management of intestinal fistula in the setting of the open
trauma and vascular and general surgery emergencies. Given
abdomen.
the lack of consistent practice, the Eastern Association for the
3. Management of the planned ventral hernia.
Surgery of Trauma (EAST) Practice Management Guidelines
Committee convened a study group to establish recommen- Process
dations for the use of open abdomen techniques in both A computerized search of the National Library of
trauma and nontrauma surgery. This has been a major under- Medicine Medline database was undertaken using the
taking and has been divided into two parts. The EAST PubMed Entrez interface. English language citations were
practice management guidelines for the open abdomen part 1 identified during the period of 1984 through 2009 using the
“Damage Control” have been published.1 primary search strategies outlined. Given the complexity of
During the development of the open abdomen part II this literature, several strategies were necessary to appropri-
“Management of the Open Abdomen,” the current literature ately capture the breadth of evidence on the topic. The search
remains contentious at best, current methods of treatment excluded case reports, reviews, letters/commentary, editori-
continue to change rapidly, and patient populations are so als, and articles focusing only on pediatric participants.
The PubMed Related Articles algorithm was also used
Submitted for publication July 21, 2010. to identify additional articles similar to the items retrieved by
Accepted for publication May 31, 2011. the primary strategy, in addition to hand searching of the
Copyright © 2011 by Lippincott Williams & Wilkins reference lists of key articles retrieved by the searches. Of
From the Division of Trauma and Surgical Critical Care (J.J.D., W.D.D., M.M.O.,
B.R.C., O.L.G., W.P.R.), Department of Surgery, and Department of Biomedical
⬃1,300 articles identified by these two techniques, only
Informatics (R.J.), Vanderbilt University Medical Center, Nashville, Tennessee; prospective or retrospective studies examining open abdom-
Division of Trauma, Critical Care, and General Surgery (D.C.C.), Department of inal management were selected, consisting of 79 institutional
Surgery, Mayo Clinic, Rochester, Minnesota; Division of Trauma, Department of studies evaluating open abdomen management strategies in
Surgery (R.A.), Bay State Medical Center, Springfield, Massachusetts; Division
of Trauma, Acute Care & Critical Care Surgery (S.B.A.), Penn State Hershey the adult surgical/critical care population. The articles were
Medical Center, Hershey, Pennsylvania; Department of Surgery (J.W.B.), Mor- reviewed by a group of 16 surgeons who collaborated to
ristown Memorial Hospital, Morristown, New Jersey; Department of Surgery produce this clinical review. The chair, vice chair, and three
(R.J.), University of Nebraska Medical Center, Omaha, Nebraska; Division of
Acute Care Surgery, Department of Surgery (A.J.K.), University of Florida HSC,
committee members (JJD, WD, MO) reviewed all the articles
Jacksonville, Florida; Division of General Surgery (J.P.K.), Section of Acute and to categorize them into the three study topics. They were
Critical Care Surgery, Washington University Medical Center, St. Louis, Missouri; distributed to all members of the study group for critical
Department of Surgery - General/Trauma and Plastic, Burn, & Reconstructive Sur- review. Each committee member was to answer the following
gery (A.L.L.), Hennepin County Medical Center, Health Partners/Regions Health, St.
Paul, Minnesota; and Division of General Surgery (C.D.W.), Department of Surgery, three questions of each article reviewed:
Southern Illinois University School of Medicine, Springfield, Illinois.
Address for reprints: Jose J. Diaz, Jr., MD, CNS, FACS, FCCM, Division of 1. What is the class of evidence in the article?
Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt Uni- 2. Are the results of the article valid based on the data
versity Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, presented?
Nashville, TN 37212; email: [email protected].
3. What is your conclusion based on the evidence the article
DOI: 10.1097/TA.0b013e318227220c provides.

502 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011 EAST Review Part 2 “Management of the Open
Abdomen”

Review 100% of patients with an open abdomen.2,4 –25 There is

During the development of this review, a common evidence that vacuum-assisted closure devices (VACD) fa-
language for the closure of the open abdomen was developed, cilitate delayed primary fascial closure with high success
which is provided in Table 1. Figure 1 is a proposed flow rates and low morbidity.3–5,7,13,14,16 –18,26 The literature de-
diagram for the closure of the open abdomen in trauma, scribes both commercially available devices (V.A.C. therapy)
emergency general, and vascular surgery. as well as “home make” noncommercial “vacuum packed–
negative pressure dressing” devices as being helpful in
Early Abdominal Fascial Closure achieving DAFC (Table 2).
In the setting of intra-abdominal sepsis, the effectiveness
Timing
of VACD to achieve DAFC has not been as successful as the
Trauma surgeons have gained an immense amount of experience seen in trauma patients.27 Wondberg et al.28 studied
experience with multiple techniques used to achieve abdom-
30 patients with intra-abdominal sepsis and an open abdomen.
inal closure of the open abdomen, but questions still remain.
They showed that only 33% of the study group was able to
How long can the abdomen remain open? When does the risk
achieve DAFC with the use of the V.A.C. therapy KCI. Failure
of complications begin to increase? Is there a specific tech-
to achieve DAFC is associated with significant financial cost,
nique that is better than the rest for closing the open abdo-
increased morbidity including wound infections and the forma-
men? At what point should all attempts at delayed fascial
tion of intestinal fistula.29 –31 Although, studies have shown that
closure be abandoned and a planned ventral hernia per-
formed? Miller et al.,2 in a study of 344 damage control using VACD in conjunction with dynamic serial fascial ad-
laparotomies demonstrated that early abdominal fascial clo- vancement, can achieve fascial closure with success rates of
sure can be achieved in the majority (63%) of damage control 86% to 100% in trauma patients.4,7,18,32
cases during the initial re-laparotomy. They showed that The Wittmann Patch (Starsurgical, Burlington, WI), an
DAFC before 8 days was associated with fewer complica- “artificial burr” Velcro-like device that is sutured to the
tions: 12% in those closed before 8 days and 52% closed after abdominal fascia, when used to manage an open abdomen has
8 days. Yet, in a study of trauma patients with an open been shown to facilitates DAFC with a success rate ⬎80% in
abdomen, massive visceral edema, and loss of domain, fascial a group of mixed trauma and abdominal sepsis patients.10,23
closure could be achieved using the V.A.C. therapy (vacuum- The Wittmann Patch can be used as a successful tool to
assisted closure, KCI, San Antonio, TX) overtime out to a provide dynamic tension in a process toward fascial clo-
4-week period with acceptable complication rates.3 With this sure.28,29 Similar to the Wittmann Patch, the use of temporary
degree of variation in timing to closure and the dreaded risk prosthetic mesh (most commonly polytetrafluoroethylene)
of life threatening complications more data were needed. with serial tightening/pleating has resulted in fascial closure
rates from 89% to 100%.14 –21 Serial/dynamic suture tighten-
Delayed Abdominal Fascial Closure ing, a technique involving repeated partial closure of the
fascia, has also been used to achieve DAFC at rates between
Techniques (Nontraumatic/Traumatic Fascial Closure) 61% and 90%.6,12,15 Table 3 describes the most commonly
Multiple studies have shown that DAFC is safe and used abdominal closure surgical techniques and the differ-
effective at achieving successful fascial closure in 65% to ences between them.
There is one randomized prospective study comparing
various techniques for DAFC. Bee et al.33 compared the use
TABLE 1. Definition of Abdominal Closures and Planned of a VACD versus using a temporary polyglactin mesh and
Ventral Hernia: Trauma, Emergency General, and Vascular showed no difference in the rate of DAFC (31% vs. 26%).
Surgery However, the success rates of DAFC in this study are signif-
Definitions of Abdominal icantly lower than other published studies, making the results
Closures and Planned difficult to interpret.
Ventral Hernia Damage
Control Initial Abbreviated Laparotomy Fascial Bridge Closure
EAFC Performed ⬍8 d of the initial damage It has been previously described, a patient with an open
control laparotomy abdomen can undergo multiple re-operations with progres-
DAFC Performed ⬎8 d of the initial damage sive closure of the fascial defect, with or without the use of a
control laparotomy
VADC, and have their fascial defect closed.3 In the setting of
Fascial bridge closure Mesh repair of fascial defect as either onlay
or underlay placement of mesh without ongoing intra-abdominal infection or the formation of an
midline approximation of the fascia enterocutaneous fistula abdominal fascial closure is often not
Acute components Performed during the initial hospitalization possible.19 Fascial closure may not be possible because of
separation for the acute illness/trauma ongoing visceral edema with loss of abdominal domain or
Planned hernia ventral Patient is discharged with a fascial defect from loss of fascia from infection. At this point, a fascial
with either skin closure only, chronic bridge closure of the resulting abdominal fascial defect may
granulating wound, or a skin graft to
protect the viscera be considered. The abdominal viscera will become cocoon in
the 14-day period to 21-day period. Attempting re-enter into
EAFC, early abdominal fascial closure.
the abdomen cavity to free the visceral off the abdominal wall

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Diaz, Jr. et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011

Figure 1. The closure of the open abdomen in trauma, emergency general, and vascular surgery flow diagram.

to allow for an easier abdominal fascial closure is both donors, bovine, and porcine animals. Biological mesh has been
difficult and dangerous. successfully used to bridge the defect as a result of an open
The surgeon is limited in the available surgical options: abdomen. Human acellular dermal matrix (HADM) (AlloDerm,
(1) bridge repair of the fascial defect using a mesh to create LifeCell Corp.) has been shown to be successfully used as a
a bridge closure, (2) performing an acute abdominal wall fascial bridge after open abdomen in multiple studies.19,37–39
reconstruction using most commonly a version of component HADM does not seem to form significant adhesions, seems to
separation, or (3) a planned ventral hernia. tolerate bacterial contamination, and does not require removal in
Fansler et al.34 reported their experience with the fascial the setting of infection.19,37,38,40 – 42
bridge closure of the open abdomen with permanent prosthetic Also, HADM has been successfully used for tissue cov-
mesh. In a series of combined trauma and abdominal sepsis erage and closure of large traumatic wounds in the setting of
patients, polypropylene was used as a fascial bridge for early significant skin and soft tissue loss.32 Once the HADM has
definitive closure. They had significant complications including developed a good granulated tissue base, a skin graft can be
a 50% enterocutaneous fistula rate, which were noted with the placed. The authors noted that when no soft-tissue coverage is
use of polypropylene mesh. Voyles et al.35 reported a similar available, keeping the graft moist is critical to the graft’s sur-
experience with a high rate of complications and fistula forma- vival. Moist saline dressings or KCI V.A.C. therapy are most
tion. The association of synthetic prosthetic mesh with bacterial often used for this purpose. Bacterial colonization with over-
colonization is well known. Once colonized or infected, the growth can occur on the grafts. This has been reported in the
prosthetic mesh acts as a chronic source of contamination.27,33,36 early postoperative phase and before the graft has had time
The use of permanent prosthetic mesh such as polypropylene, to revascularize. The use of silver sulfadiazine or sulfa-
polytetrafluoroethylene, and polyester products has been aban- mylon-soaked dressings on the graft should decrease bacterial
doned in these circumstances because of the high rates of counts until vascular in-growth has occurred and may prevent
complications seen with their use. early graft loss from infection.
Biological mesh material has been commercially available The long-term success of using HADM as a fascial bridge
for almost 10 years. Biological mesh originates from human for hernia repair after an open abdomen technique is unclear.

504 © 2011 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011 EAST Review Part 2 “Management of the Open
Abdomen”

TABLE 2. Delayed Abdominal Fascial Closure

References Year Class N Evidentiary Bullet
Smith et al. 1992 III 13 Temporary skin coverage is more effective than synthetic mesh in promoting delayed primary fascial
coverage
Wittmann 2000 III 128 Use of an “artificial burr” material used in peritonitis had 93% closure are during initial hospitalization
Garner et al. 2001 III 14 VAC combined with serial fascial closure is successful in this small case series (90%)
Koniaris et al. 2001 III 13 “Dynamic retention” sutures (AKA—full thickness/transabdominal wall horizontal mattress sutures in a
retention suture fashion) assist in abdominal closure, no fistulas recorded
Miller et al. 2002 III–⬎II 22 Primary facial closure may be done up to a month after initial operation with VAC sponge, with no
difference in complication rate
Navsaria et al. 2003 III 55 TAC with modified sandwich is easy, rapid, cost-effective, and effective in containing abdominal wall
contents
Suliburk et al. 2003 III 55 VAC use along with serial fascial closure achieves high rate of delayed primary fascial closure (86%)
Guy et al. 2003 III 9 Early single stage closure of open abdomen resulting from ACS may be achieved with acellular dermis and
bipedicle flaps
Miller et al. 2004 II 53 VAC extends the potential delayed primary fascial closure deadline to as much as 3–4 wk with acceptable
fistula rate
Howdieshell et al. 2004 III 88 TAC with silicone sheeting is safe and effective
Stone et al. 2004 III 48 Vacuum-assisted closure is effective with rates of delayed primary closure comparable to other techniques in the
trauma population, fluid balance less than 20 L positive is associated with improved closure success
Tsuei et al. 2004 III 71 Trauma patients more likely to achieve fascial closure, GI sepsis more likely to require mesh closure and
pancreatitis more likely to have no closure. Mortality: trauma 20%, GI 36%, and pancreatitis 43%.
Incidence of fistula 16.9% (trauma 12%, GI 16%, and pancreatitis 24%)
Howdieshell et al. 2004 III 88 TAC with silicone sheeting is safe and effective
Cipolla et al. 2005 III 17 Four step algorithm: (1) delayed primary fascial closure within 48 h, (2) KCI VAC up to 7-d postop, (3)
Wittmann Patch after 7 d of KCI VAC, and (4) absorbable mesh with skin graft after 3 wk
Cothren et al. 2006 III 14 KCI VAC-assisted fascial approximation using serial fascial tightening is an effective method for early
abdominal closure and may avoid planned ventral hernia
Scott et al. 2006 III 37 Early aggressive closure of the open abdomen is possible with a combination of vacuum pack, vacuum
assisted wound management, and HADM
Vertrees et al. 2006 III 29 Sequential tightening of a Gore-Tex mesh bridge, may be a useful tool for fascial closure
Vogel et al. 2006 III 276 Failure of primary fascial closure is associated with more extra abdominal infectious complications
Perez et al. 2007 II 37 VAC system is a useful tool in the severely ill general surgery patient with large abdominal wounds. Facial
closure rates ⫽ 70%. Patients closed with VAC system had similar quality of physical and mental health
scores at 3 months compared to “controls”
Hadeed et al. 2007 III 24 The rate of closure using the Wittmann patch is equivalent to other commonly used methods
Kushimoto et al. 2007 III 11 Bilateral anterior rectus sheath turnover flaps may be useful for definitive closure of the open abdomen that
is not amenable to delayed primary fascial closure, particularly if the defect is less than 15 cm at
greatest width
Petersson et al. 2007 III 7 Vacuum-assisted delayed primary fascial closure can be effective with dynamic serial tensioning of mesh-
mediated fascial traction
Gaddnas et al. 2007 III 11 Continuous retention suture may be helpful in achieving delayed primary fascial closure through dynamic
serial tension
Defranzo et al. 2008 III 37 VAC-assisted closure may facilitate delayed primary fascial closure and simplify abdominal wall
reconstruction with low morbidity
Vertrees et al. 2008 III 85 Complex open abdominal wounds have lower delayed primary fascial closure rates and are more likely to
require biologic or non-biologic prosthesis
Singh et al. 2008 III 10 HADM provides for successful bridge in open abdomens both clean and infected fields with low
complication rates
Teixeira et al. 2008 II 900 The majority of damage control laparotomy abdomens can be closed primarily, which may substantially
reduce development of enterocutaneous fistula. Deep space infection and intra-abdominal abscess are
independently associated with failure to close the abdomen
Tieu et al. 2008 III 29 Wittmann patch results in ⬎80% rate of delayed fascial closure in trauma and EGS patients
Wondberg et al. 2008 III 30 KCI vacuum-assisted closure of complex abdomen has worse outcomes compared to published closure
rates trauma patients
de Moya et al. 2008 II 10 HADM effectively closes/bridges complicated abdomen with low rate of fistula formation. Laxity is long-
term complication
Weinberg et al. 2008 III 159 Wittmann patch increases rate of delayed fascial closure with no difference in abdominal complications
Bee et al. 2008 I 51 Patients requiring TAC, no difference between negative pressure devices and primary Vicryl mesh closure
with regard to mortality, fistula rate, or primary closure rate. Of all methods, KCI VAC is associated
with the highest hospital charges

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Diaz, Jr. et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011

TABLE 2. Delayed Abdominal Fascial Closure (continued)

References Year Class N Evidentiary Bullet
Reimer et al. 2008 III 23 Dynamic fascial closure system may assist in delayed primary fascial closure in the complex abdomen
Vertrees et al. 2009 III–⬎II 65 Delayed colonic repair is acceptable in the face of damage control; primary repair is more likely to fail in
the setting of concomitant organ injury
Awad et al. 2009 III 17 Alloderm is susceptible to infection from source control bacterium. Silver-based antimicrobials placed in
conjunction with dressing changes may prevent critical colonization; during the time, it takes to
revascularize AlloDerm graft
Subramonia et al. 2009 III 51 KCI VAC provides negative pressure wound therapy for open abdomen with acceptable complication rate
Gonullu et al. 2009 III 37 Bogotá bag is inexpensive when used for TAC and allows for abdominal viewing
37 Studies, 29 Level III, 7 Level II, 1 Level 1
TAC, temporary abdominal closure.

TABLE 3. Definitive Abdominal Fascial Closure of the Open Abdomen

Techniques
DAFC Vacuum-assisted closure devices* Wittmann Patch (WP) Serial/dynamic suture closure
Description Creation of a negative pressure “Artificial burr” Velcro-like device to Placement of fascial sutures placed
dressing to pull the fascial sequentially pull the fascia together over a series of laparotomies until
edges together; performed over over a period of several days during the fascia is closed; may be used
a period of several days during serial laparotomies until the fascia can with a vaccum system
serial laparotomies until the be closed
fascia can be closed
Fascial trauma None Serial tension
Fascial closure 33–100% 77–93% 61–90%
rates
Trauma 86–100% 75–100% 61–90%
†
Peritonitis 33–75% 93% No data
Time line to Mean time 9.5 d, safe up to 3 wk Mean time 13–15.5 d, safe up to 3 wk Mean time 9.5 d, safe up to 3 wk
DAFC
Complications Intestinal fistula Intestinal fistula, surgical wound Intestinal fistula, surgical wound
infection infection
Fascial bridge Onlay with biologic or synthetic Underlay with biologic or synthetic mesh Interposition placement of mesh
closure mesh
Description Mesh is placed on top of the Mesh is placed underneath the fascia and Mesh is sewn directly to the edge of
fascia and sown into place with sewn into place with several (3–5) cm the fascia
several (3–5) cm of overlap of overlap
Benefits Potential long-term success Potential long-term success None
Complications Biologic mesh high rate of hernia Biologic mesh high rate of hernia Highest rate of recurrence
recurrence recurrence
Acute components Step-up approach
separation Release of the external oblique Plus—separation of parts or release of Plus—“Open Book” rectus flip
muscle the rectus fascia
* Included VAC and vacuum pack (perforated plastic sheet, surgical towels, drains, and Ioban drape).
†
Only one study.9

There are a number of studies suggesting that the long-term The use of HADM as a fascial bridge under the cir-
strength of the HADM decreases overtime. This multifactorial cumstances of the unclosable abdomen after damage control
may be attributable to collagen re-modeling, mesh attenuation, is supported by the available literature. It protects the viscera
or tissue growth resulting in a high rate of hernia formation.43,44 from fistulization and may provide definitive abdominal wall
However, HADM bridge ventral hernia repairs have been strength. Yet, the long-term results in providing definitive
performed after trauma and many patients have had definitive fascial strength are not known.
repairs.16 Singh et al.,38 report on 10 liver transplant patients treated
with an open abdomen and closed with an HADM fascial bridge. In Acute Component Separation
short-term follow-up (10 months), there were no cases of herniation One option for closure of the open abdomen is an acute
noted. Conversely, de Moya et al.,45 demonstrated that patients abdominal wall reconstruction using the component separa-
treated with an HADM bridge repairs and that at 1-year follow-up tion techniques. Ramirez et al.,46 were the first to describe the
had evidence of recurrent hernia or significant abdominal wall component separation technique for reconstruction of large
laxity. abdominal wall fascial defect without the use of prosthetic

506 © 2011 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011 EAST Review Part 2 “Management of the Open
Abdomen”

mesh. In its basic form, the technique is as follows: (1) the traumatized bowel, and nontraumatized bowel, which has
anterior abdominal wall skin flaps are developed and dis- been exposed for a period of time. This is one of the most
sected out to the anterior superior iliac spine and the chest devastating complications of the open abdomen. The fore-
wall, (2) the aponeurosis of the external oblique muscle is most risk factors are the inability to perform primary
divided lateral to the semilunar line on to the chest wall to the abdominal facial closure in a timely manner, and deep
level of the xiphoid, (3) free up the external oblique, which space infections, and intra-abdominal abscess.19
will allow the rectus myofascial component to be mobilized The use of polypropylene mesh for bridge repair of the
medially, and (4) the midline is sutured together. The com- open abdomen has been shown to have unacceptably high
ponent separation has become the most commonly used rates of fistula complications and is no longer recommended
surgical technique for closure of large “planned” ventral for definitive closure in the acute setting of open abdominal
hernias with a skin graft during the elective reconstructive management.34 Fistulae arising during early clinical manage-
phase.11,47,48 Its use for acute definitive closure in the setting ment of open abdomens result in leakage of intraluminal
of an open abdomen has not been well studied. Formal contents over the unprotected surface of bowel. The patient
component separation is generally considered an “elective” with an enteroatmospheric fistula has extremely complicated
reconstructive technique. Its use in the acute setting in the critical care, open abdomen, and nutritional management
face of resolving intra-abdominal sepsis, visceral, and ab- issues. Inadequate fistula management will result in acute
dominal wall edema as a result of systemic inflammatory protein calorie malnutrition, electrolyte disturbances, and
response syndrome and ongoing systemic sepsis is not advis- prolonged hospitalization.53
able. Once a formal component separation has been per- The key components of management of the patient with
formed, it is eliminated as an option for later abdominal wall an enterocutaneous fistula are as follows: (1) sepsis control,
reconstruction. (2) nutritional support, and (3) local wound care (Fig. 2). A
There are at least three versions of the component key to treating entero-atmospheric fistulas is management of
separation technique. The original description by Ramirez et the initial inciting events and treatment of resulting compli-
al. is described above. Another surgical technique is the cations. Source control and eradication of sepsis are essential.
“separation of parts” by the Memphis group. There is also a If possible, promote spontaneous closure and diminish the
“open book” technique, which in addition to the lateral catabolic strain on the tissues.54 In patients with intestinal
release of the external oblique, the rectus fascia (either fistulas with a tract or skin coverage, management of fistula
anterior or posterior) is flipped into the midline using the output has been assisted by hormonal agents; however, ran-
domized control trials do not favor octreotide as the standard
linea alba as the fulcrum to extend the midline. The rectus
of care.55 Medical management has decreased the need for
roll-over technique by itself has been studied in the setting of
operative management of intestinal fistulas. More than 50%
definitive closure after the open abdomen in both trauma and
of patient with intestinal fistulas will require surgery for the
general surgery patients. The anterior rectus fascia is incised
control of sepsis and subsequent surgical repair for failure to
near its lateral border on both sides, medialized, and sewn in
the midline. In a series of 29 patients, the technique was used
successfully to close defects up to 15 cm.30 In follow-up of 65
months, no recurrent abdominal wall hernias were noted,
although mid-abdominal bulging was noted in 50% of
patients.

Enteroatmospheric Fistula as a Complication of

the Open Abdomen
During the initial damage control laparotomy, the open
abdomen technique is used for rapid re-entry into the abdo-
men. DAFC can be commonly achieved once all the intra-
abdominal injuries have been addressed. In the setting of
intra-abdominal sepsis and/or pancreatitis, DAFC is not as
successful.49 It is well recognized that the longer the time
period to fascial closure, the higher the complication rates
especially intestinal fistulas.50,51 In addition, the obese patient
is at increased risk of having more complications after dam-
age control laparotomy and longer time period to primary
fascial closure.50,52 Trauma patients who required a prolong
period of an open abdomen as part of their damage control
management have five times the fistula rate verses those
patients who were closed during the initial trauma laparot-
omy. The enteroatmospheric intestinal fistula results in the
setting of the open abdomen. The fistula can develop as a Figure 2. Intestinal fistula complicating the open abdomen
result of an anastomotic leak with exposed suture lines, flow diagram.

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Diaz, Jr. et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011

close spontaneously.56,57 Nutrition support either enteral or development of a “neo-peritoneal cavity.”63 An essential
parenteral is considered a critical supportive measure to management priority is to stage the “elective” gastrointestinal
prevent malnutrition in an already debilitated patient.58 Al- reconstruction when the patient’s sepsis has resolved. After
though, a full discussion of the management of intestinal the inflammatory process within the abdominal cavity has
fistula is beyond the scope of this article, Table 4 provides resolved, the intra-abdominal adhesions will progress through
additional literature. the various stages of inflammation to vascularize and loosen
Local wound care can be extremely problematic in the fibrous adhesions resulting in a safer operative procedure.64
patient with an open abdomen and an entero-cutaneus fistula. Even in the most optimized patient, entero-atmospheric fis-
In an attempt to mitigate the inflammatory state preventing tulas remain among the most challenging problems, a surgeon
resolution of the entero-atmospheric fistula, Jamshidi and will face.
Schecter59 treated seven patients with direct application of a
biological dressing (HADM and/or cadaveric split thickness Planned Ventral Hernia
skin graft). Five of this series of seven closed with only two Fabian et al.65 and other authors are credited with the
requiring further operative management. Physiologically sim- initial description of the stages of damage control. The goals
ilar, the application of skin graft to the granulated wound bed of damage control are (1) patient survival, (2) reconstruction
can have good results with as much as 93% graft take at 1 of the patient’s traumatic injuries with the final goal and (3)
week.60 The use of an innovative negative pressure dressings being abdominal fascial closure.47,62,66,67 As noted above,
or the KCI V.A.C. therapy to collect the draining succus there are multiple techniques to achieve early or DAFC.
entericus to keep the open abdomen clean can be a daily When this is not possible, the planned ventral hernia tech-
wound management issue. An innovative option for improv- nique is used.
ing wound care is the creation of the “floating stoma.” Recent Once it has been determined that the abdominal fascia
case studies have described techniques for “floating will not come together because of massive visceral edema,
stoma” with or without KCI V.A.C. therapy of the wound loss of domain, and/or loss of abdominal wall tissue, the only
bed in attempts to simplify treatment before and after option left is a planned ventral hernia or fascial bridge with
definitive repair.61 biological mesh or absorbable mesh.68,69 The initial goal of a
The restoration of gastrointestinal continuity at the time planned ventral hernia is to keep the viscera within the
of the abdominal wall reconstruction is safe and the preferred abdominal cavity. This is accomplished by using absorbable
treatment for entero-atmospheric fistula.62 Success depends mesh (Vicryl [Ethicon] or Dexon [Covidien]) to prevent
on the achievement of the goals set out in the management evisceration. This allows time for the viscera to adhere
phase; the eradication of sepsis, optimizing nutrition status together. This occurs during the course of 2 weeks to 3
(albumin ⬎3.25 g/dL), and delaying operative repair a min- weeks. Once the base of the open wound has granulated, a
imum of 3 months to 12 months to allow for the skin graft can be performed to cover the viscera. If the fascial

TABLE 4. Enterocutaneous and Entero-atmospheric Fistula

References Year Class N Evidentiary Bullet
Sleeman et al. 1995 III 12 Previous open abdomen is not contraindication to operation for restoration of bowel continuity and
abdominal wall reconstruction
Fansler et al. 1995 III 26 Polypropylene should not be used as a temporary or definitive closure in the acute setting of an open
abdomen because of ⬎50% fistula rate
Dumanian et al. 1996 III 64 Skin grafted may help simplify wound care including those with fistulas
Heller et al.75 2006 III 21 Use of KCI VAC achieves delayed primary fascial closure successfully with low morbidity in facial
dehiscence
Sriussadaporn et al. 2006 III 8 Planning for closure of the open abdomen with fistula should take into account resolution of acute
catabolic phase, metabolic indicators such as Albumin ⬎3.0 (average greater than 4 months)
Jamshidi and Schecter 2007 III 7 Intestinal fistulas after open abdomens may benefit from closure with application of biologic dressings
(alloderm and/or cadaveric skin graft)
Connolly et al. 2008 III 71 Delayed primary fascial closure can be more commonly achieved in trauma vs. abdominal
sepsis/pancreatitis, which can be more difficult
Teixeira et al. 2008 II 900 The majority of postdamage control laparotomies can be closed primarily with a reduced incidence
fistula. Deep space infection and intra-abdominal abscess are independent risk factors for failure to
close the abdomen
Teixeira et al. 2009 III 2373 Fistula rate is low in trauma population (1.5%) but is significantly higher in open abdomens (7%) and is
significantly associated with inability to perform delayed primary fascial closure (54%). Management
is associated with longer ICU LOS and expense
Duchesne et al. 2009 III 104 Severely obese are vulnerable patients for complications after damage control laparotomy
Haricharan et al. 2009 III 148 Overweight and obesity is associated with longer time to delayed primary fascial closure and higher
complication rates
11 Studies, 10 Level III, 1 Level II, No Level I

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The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011 EAST Review Part 2 “Management of the Open
Abdomen”

TABLE 5. Planned Ventral Hernia

References Year Class N Evidentiary Bullet
Fabian et al. 1994 III 88 Planned 4-stage; 1 prosthetic insertion, 2 prosthetic removal, 3 planned ventral hernia ⫾ skin
graft, 4 definitive reconstruction, open abdomen closure is safe, inexpensive, and provided
good results with had moderate size fascial defects
Brenneman et al. 1995 III 9 Acute, traumatic abdominal wall disruptions, present major reconstruction challenges.
Reconstruction of the traumatic damage can be delayed and optimal after intestinal
continuity has been achieved
Sleeman et al. 1995 III 12 Previous open abdomen is not contraindication to operation for restoration of bowel continuity
and abdominal wall reconstruction
Yeh et al. 1996 III 13 Fascial closure possible with or without mesh onlay and low morbidity after silastic sheet
temporary closure and skin grafting resulting in good functional and aesthetic results
Mathes et al. 2000 III 106 Mesh closure for midline hernias and flap closure for lateral hernias can be accomplished with
acceptable complication rates
Cohen et al. 2001 III 24 Staged reconstruction should allow for early visceral coverage (Gortex) followed by skin
graft. Definitive repair should be delayed greater than 7 months, skin graft does not need to
be removed entirely, dermabrasion with resulting neo-peritoneum is acceptable
Sukkar et al. 2001 III 64 Definitive repair of the hernia with components separation/flap is highly successful with low
morbidity
Jernigan et al. 2003 III 274 A 3-stage approach to giant abdominal wall defects using absorbable mesh, skin graft, and
eventual component separation has low complication rates with 8% fistula, 8% mortality,
and 5% recurrent hernia rate
Sriussadaporn et al. 2003 III 9 Bilateral bipedicle flaps is an effective management of the open abdomen to achieve early
definitive closure. Stoppa repair effective in late repair of giant ventral hernias
Howdieshell et al. 2004 III 88 TAC with silicone sheeting is safe and effective
Cipolla et al. 2005 III 17 Four step algorithm: (1) delayed primary fascial closure within 48 h, (2) KCI VAC up to 7-d
postop, (3) Wittmann Patch after 7 d of KCI VAC, and (4) absorbable mesh with skin graft
after 3 wk
Rodriguez et al. 2007 III 23 Biologic and synthetic onlay mesh may support primary fascial closure with or without
component separation as well as interpositional mesh during abdominal wall reconstruction
Vertrees et al. 2008 III 85 Complex open abdominal wounds have lower primary fascial closure rates and are more likely
to require biologic or nonbiologic prosthesis
Teixeira et al. 2008 II 900 The majority of damage control laparotomy abdomens can be closed primarily, which may
substantially reduce development of enterocutaneous fistula. Deep space infection and intra-
abdominal abscess are independently associated with failure to close the abdomen
Bee et al. 2008 I 51 Patients requiring TAC, no difference between negative pressure devices and primary vicryl
mesh closure with regard to mortality, fistula rate, or primary closure rate. Of all methods,
KCI VAC is associated with the highest hospital charges
Taner et al. 2009 II 13 Acellular dermal matrix is satisfactory for some fascial replacement applications such as
parastomal hernias
Liu et al. 2009 III 41 Autogenous, pedicle, demucosalized small intestinal sheets can be used for abdominal wall
reconstruction of infected complex abdominal wall defects. Mean size of defect closed was
108 cm2. Long-term follow-up show few complications other than regeneration of intestinal
mucosa through meshed skin graft
17 Studies, 14 Level III, 2 Level II, 1 Level I

defect is not large, another option is to elevate skin flaps and adhered together. The prosthetic mesh is removed and the
perform a skin only closure.70 Caution must be exercised granulation bed is skin grafted. Others have used bilateral
when elevating skin flaps in the setting of continued intra- bipedal flaps to cover the granulation bed with skin. The
abdominal sepsis, lack of source control, and massive visceral goal is to decrease the incidence of intestinal fistula
edema; because this setting has a high risk of skin flap formation.37,72
infarction and flap loss. In this setting, allowing the wound The introduction of biological mesh has been used in an
base to progress to a good granulated base and proceeding to attempt to do single stage repairs of ventral hernias.16,38 The
skin graft tissue coverage may be the safest option. Regard- data to date suggests that the majority of patients repaired
less of the technique used, visceral coverage is essential to with biological mesh may develop laxity of the repair result-
decrease metabolic burden and prevent the formation of ing in a hernia 6 months to 12 months later.45 The role of
entero-atmospheric fistulae as a result of trauma from expo- biological mesh in the healing process has not been com-
sure or dressing changes. pletely elucidated.
Temporary abdominal closure with silicone sheets or The final stage of damage control is an “elective”
Gortex has also been used to keep the abdominal contents abdominal wall reconstruction.71,73 Because of the complex-
from eviscerating.11,71 This is done until the viscera have ity of this topic, the EAST Open Abdomen Committee is in

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Diaz, Jr. et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 2, August 2011

TABLE 6. Classification of the OA

Currently, there is no sponsoring organization of the classi-
fication proposed and it has not been studied or validated.
Grade Description However, a standard classification system of the open abdo-
1A Clean OA without adherence between bowel and abdominal men is necessary, if a scientific approach is to be taken in
wall or fixity (lateralization of the abdominal wall) regards to this vexing clinical problem (Table 6).
1B Contaminated OA without adherence/fixity
2A Clean OA developing adherence/fixity
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