The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review

Abstract

Background The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. Methods A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. Results The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome—The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. Conclusion Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

“…Damage control surgery for abdominal trauma and/or for source control in severe abdominal sepsis and the management of abdominal compartment syndrome are the main clinical conditions in which OA ( Figure 3 ) is currently applied [ 12 , 17 , 27 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ].…”

“…Damage control surgery for abdominal trauma and/or for source control in severe abdominal sepsis and the management of abdominal compartment syndrome are the main clinical conditions in which OA (Figure 3) is currently applied [12,17,27,[73][74][75][76][77][78][79][80]. The etiology of an EAF may often be multifactorial and represent a combination of several independent factors including the primary diagnosis and cause for OA treatment, iatrogenic lesions of the intestinal tract during laparostomy/relaparotomy, postoperative anastomotic rupture, dehydration, swelling and ischemia of the intestine, exposure of the bowel to materials used for temporary abdominal closure, adhesions between the bowel and the abdominal wall, wound infections.…”

“…The abnormal fistulous connection can occur between the gastrointestinal tract and the skin (enterocutaneous fistula, ECF), another portion of the gastrointestinal tract (entero-enteric fistula) or the urogenital tract. The increasingly widespread use of open abdomen (OA) techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of the so-called entero-atmospheric fistulas (EAF) [ 12 , 13 , 14 , 15 ].…”