Open AbdomenEdit

Open abdomen is a surgical approach in which the abdominal cavity is intentionally left open after an initial laparotomy, followed by temporary abdominal closure to protect the viscera and allow staged interventions. This strategy is most often employed in damage-control scenarios where physiologic derangements from hemorrhage, contamination, or edema outpace the body’s ability to recover with definitive, single-stage surgery. By keeping the abdomen open, clinicians can rapidly re-enter the cavity for source control, reassessment, and ongoing resuscitation, rather than forcing a closure during the same unstable operation. The method has become a standardized option in modern trauma and critical care surgical practice, but it also carries risks and prompts ongoing debate about patient selection, timing, and resources. For context, see discussions of damage-control surgery and abdominal compartment syndrome as related concepts.

In practice, open abdomen is managed with a plan for temporary closure and a staged return to the operating room for definitive fascial closure when feasible. The technique blends acute life-saving needs with multidisciplinary care, including critical care management, nutrition, wound care, and infection control. The approach is relevant to several conditions, including severe trauma, necrotizing intra-abdominal infections, and certain cases of necrotizing pancreatitis, as well as situations requiring rapid re-operation for ongoing contamination or bleeding. Related concepts include temporary abdominal closure, negative pressure wound therapy, and strategies for eventual closure of the fascia.

Indications and patient selection

Severe trauma with life-threatening hemorrhage or contamination where rapid control is essential, and physiologic stabilization is unlikely with a single operation. See trauma and damage-control surgery for broader context.
Abdominal catastrophes requiring staged debridement or source control, such as extensive intra-abdominal infection or necrosis.
Abdominal compartment syndrome where edema or bleeding prevents safe primary closure, creating a need for staged relief of pressure.
Necrotizing pancreatitis or complex intra-abdominal processes where ongoing re-entry and assessment improve outcomes.
Situations where the risks of a delayed, definitive closure are outweighed by the benefits of rapid re-access and physiologic optimization.

Contraindications or situations where open abdomen might be inappropriate include cases with little likelihood of physiologic recovery, limited resources, or scenarios in which rapid definitive repair is safer and feasible. Clinicians weigh patient-specific factors, including age, comorbidity burden, infection risk, and the ability to provide intensive postoperative care.

Techniques and closure strategies

Temporary abdominal closure (TAC) methods: TAC is a core component, designed to protect the abdominal contents while allowing edema resolution and access for re-entry. Common approaches include negative pressure wound therapy (NPWT) and other open-abdomen dressings. See negative pressure wound therapy and temporary abdominal closure.
Dynamic fascial closure: Techniques that apply gentle traction or staged closure to achieve definitive fascial closure as edema subsides. This includes approaches like mesh-assisted fascial traction and dynamic retention methods.
Bogota bag and other temporary coverings: Historically, simple temporary closures such as a sterile bag or nonadherent dressings were used; modern practice favors systems that promote drainage, protect viscera, and support closure planning. See Bogota bag.
Nutrition and infection control: Open abdomen requires meticulous critical care, including early nutrition, infection prevention, and careful fluid management, with coordination among surgeons, intensivists, nurses, and wound-care specialists.

Timing considerations are central to these techniques. Early fascial closure (often within 24–72 hours when physiologic parameters permit) is associated with better long-term abdominal wall integrity, but may not be feasible in many patients with significant edema, ongoing contamination, or instability. Delayed closure strategies focus on stabilizing the patient and controlling infection before attempting fasciotomy closure, with re-operations as needed to achieve definitive repair. See fascia and fascial closure for more on closure concepts.

Management and outcomes

Re-operations and monitoring: Patients with open abdomen typically require multiple re-operations to debride, reassess, and plan closure. This care pathway depends on ICU resources, surgical expertise, and event-driven needs such as new infections or ongoing bleeding.
Complications: Known risks include fistula formation (including enteroatmospheric fistulas in some cases), ventral hernia after closure, infection, fluid loss, electrolyte disturbances, and prolonged ICU/hospital stays. The likelihood of certain complications increases with the duration the abdomen remains open.
Outcomes: In appropriately selected patients, open abdomen can improve survival by enabling timely source control and physiologic optimization. However, it also imposes risks and a longer trajectory of recovery, with some patients ultimately requiring complex reconstructive procedures.
Long-term considerations: Even after definitive fascial closure, patients may experience hernia formation or abdominal wall dysfunction, necessitating further repair and rehabilitation.

Controversies and debates

Timing of fascial closure: Clinicians debate the optimal window for moving from a temporary to a definitive closure. Early closure may reduce the risk of ventral hernia but could be unsafe in the setting of persistent edema or infection; delayed closure prioritizes stabilization but carries its own complications and resource use.
Patient selection and resource use: Open abdomen is resource-intensive, requiring ICU care, specialized TAC devices, and careful multidisciplinary management. In settings with constrained resources, clinicians must balance potential survival benefits against costs and the availability of personnel and equipment.
Device choice and technique: The choice of TAC method (e.g., NPWT versus traditional dressings) influences drainage, infection risk, and time to closure. Evidence comparing methods continues to evolve, guiding practice toward approaches that optimize patient outcomes while minimizing complications.
Non-traumatic indications: The use of open abdomen outside trauma (for example, in complex intra-abdominal infections or pancreatitis) remains subject to ongoing research and debate, with varying recommendations across centers and guidelines.
Ethical and policy considerations: As with any high-resource, high-intensity intervention, discussions occur about when such aggressive care aligns with a patient’s goals, prognosis, and overall quality of life. Decision-making often involves families, specialists, and institutional policies to ensure that care aligns with evidence and patient values.

History and evolution

Open abdomen emerged from the broader concept of damage-control surgery, developed to improve survival in severely injured patients by prioritizing physiologic stabilization over immediate definitive repair. Advancements in temporary closure technologies, wound management strategies, and critical care have refined the approach, reducing some complications and enabling safer staged operations. The field continues to evolve with ongoing research into closure timing, device performance, and long-term outcomes.