Damage Control Laparotomy and Management of The Open Abdomen

D a m a g e C o n t ro l L a p a ro t o m y
a n d M ana g emen t o f t h e
Open Abdomen
Jennifer Serfin, MD*, Christopher Dai, DO,
James Reece Harris, DO, Nathan Smith, DO
KEYWORDS
Damage control laparotomy Open abdomen management
Intra-abdominal hypertension
KEY POINTS
Open abdomen management is safe and effective for a select group of patients.
There are multiple techniques that can be used to reduce fluid loss, maintain abdominal
sterility, and improve possibility of closure.
Delayed closure of the abdominal cavity is sometimes the best option in patients who are
unstable, do not have complete control of their original pathology, or would have negative
outcomes because of abdominal closure.
INTRODUCTION AND HISTORY OF THE OPEN ABDOMEN
Open abdomen management (OAM) was initially described during World War II as an
option to control the “burst abdomen” after abdominal war wounds.1 Dr Ogilvie
described the multitude of challenges that these injuries posed. For one, they were
normally composed of multiple wounds, which destabilized the abdominal wall. These
wounds would be associated with contamination leading to adhesions in the early
setting, which would be denser and more numerous than in a nontraumatic setting.
Finally, he described the challenge of being the second surgeon as the initial operation
was likely performed by another. Given these challenges and the large abdominal wall
defect not amenable to primary closure, OAM was introduced. Dr Ogilvie’s attempts at
temporary management included a canvas soaked in Vaseline sutured to the fascial
edges as a bridging mesh. This would prevent further retraction of fascial edges
and would bolster the abdominal wall enough to allow use of respiratory muscles.1
As his experience in the theater of war increased, he enhanced his management of
combat wounds. He extrapolated his experience to non-wartime injuries. With his and
Good Samaritan Regional Medical Center, 3600 NW Samaritan Drive Suite H407, Corvallis, OR
97330, USA
* Corresponding author. Good Samaritan Regional Medical Center, 3600 NW Samaritan Drive,
Corvallis, OR 97330.
E-mail address: [email protected]
Surg Clin N Am - (2023) -–-

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2 Serfin et al
past surgeon’s experience, immediate primary closure had fallen out of practice in
traumatic wounds and delayed closure prevailed as the standard of care. He believed
that this standard of care should also be extended to non-traumatic pathology citing
the prevalence of abdominal incision infections in appendicitis and duodenal perfora-
tions. He proposed closure of abdominal wounds 4 days after the index operation to
decrease the future possibility of incisional infection.2
OAM continued to be refined for the next few decades mostly in the setting of intra-
abdominal sepsis. Intra-abdominal sepsis had a high mortality rate and keeping an
abdomen open served to treat the abdominal cavity essentially as an abscess cavity.
Dr Steinberg described a temporary closure over gauze packs in suppurative perito-
nitis. This allowed a second look in 48 to 72 hours after the index operation and
delayed closure.3 At about the same time, surgeons in Belgium tested planned re-
laparotomies 2 to 3 days after the initial laparotomy for peritonitis. This technique
demonstrated a mortality of approximately 29%, which was an improvement from
the previously observed 73% in the general surgery population. Planned re-
laparotomies gained traction as an accepted procedure and were continued until
the abdomen could no longer be closed. At that point, the abdomen was temporarily
closed, packed with soaked gauze or with placement of a nonabsorbable mesh to
retain abdominal contents.4
Initial techniques of OAM and temporary closure exposed many of the complica-
tions that we know today. These included insensible fluid loss, entero-atmospheric
fistulae, and loss of domain. Continued morbidity associated with OAM and temporary
closure drove the development of new techniques to avoid these complications.
Absorbable mesh, plastic bags, Velcro, and zipper techniques were refined into the
temporary abdominal closure (TAC) devices that we use today. As the techniques
expanded so did the indications for the use of TAC. What was initially recognized
solely as a strategy to manage intra-abdominal sepsis now included intra-
abdominal hypertension and damage control surgery.
DISCUSSION
Indications for Open Abdomen Management
OAM is indicated in abdominal compartment syndrome (ACS), intra-abdominal
sepsis, or damage control surgery for hemorrhage and traumatic injury. Although it
initially gained traction in the realm of intra-abdominal sepsis, the landscape of
OAM in surgery changed. With the increasing prevalence of damage control surgery
and established treatment guidelines for intra-abdominal hypertension and ACS,
OAM use became more common.
Intra-Abdominal Hypertension/Abdominal Compartment Syndrome

ACS as a clinical entity is defined as intra-abdominal pressure greater than 20 mm Hg
and new end-organ failure.5 The pathophysiology of ACS is related to both direct and
indirect effects on intra-abdominal organs as well as systemic effects. The increased
abdominal pressure leads to decreased venous return to the heart, decreased end-
organ perfusion, and decreased diaphragmatic excursion, leading to the commonly
seen signs in ACS.
Theories relating to ACS have been documented as early as the nineteenth century.6
Although there were many early descriptions, including its effects on solid organs, its
effect on preload and the descriptions of “burst abdomen” after the closure of an
abdomen under tension, its place as a clinical entity was not yet fully recognized. In
2013, the consensus guidelines of intra-abdominal hypertension and ACS were
DCL and Management of the Open Abdomen 3
updated by the World Society of the Abdominal Compartment Syndrome. In their

guidelines, they recommend decompressive laparotomy in two settings: primary
ACS with associated organ failure or secondary ACS with progressive worsening or
end-organ function. Primary ACS is ACS due to “injury or disease in the abdominopel-
vic region,” whereas secondary ACS is due to systemic disease not originating in the
abdominal cavity.5
Intra-Abdominal Sepsis
Intra-abdominal sepsis is one of the original indications for OAM. In the setting of se-
vere peritonitis, continued reinspections allowed for control of infection essentially
treating the abdomen as a large abscess cavity. Historically, some investigators advo-
cated for continued re-laparotomies until the abdomen could no longer be closed.
Current techniques allow for continued “re-looks” while safely controlling intra-
abdominal contents and fluid losses while treating intra-abdominal sepsis. The goal
in these situations would be to continue OAM until the infection is controlled or until
further sources of infection within the peritoneal cavity are no longer identified.
Damage Control Laparotomy

In the setting of severe injury, whether traumatic or pathologic, laparotomy can be
aimed to immediately control the injury while allowing the patient to physiologically
respond to the insult. This is usually indicated in the instances of significant hemor-
rhage requiring packing, need for large volume resuscitation, correction of physiologic
parameters such as acidosis or hypothermia or need for staged reinspection and
repair of destructive injuries. In these situations, the care of these patients is per-
formed in phases.
Phase 0 comprises the initial presentation and triage until initial laparotomy (Fig. 1).
Phase 1 is focused on limiting operative time while controlling the cause of the
Fig. 1. Open abdomen with omentum covering majority of bowel.
4 Serfin et al
physiologic insult. This includes hemorrhage and contamination control while ensuring
perfusion to end organs and extremities. Phase 2 involves resuscitation of the patient
before definitive repair in phase 3. OAM is a vital component of phases 1 and 2 of dam-
age control surgery, OAM allows for time to adequately resuscitate the patient before
definitive management and/or closure.7
TYPES OF TEMPORARY ABDOMINAL CLOSURE FOR OPEN ABDOMEN

MANAGEMENT
TAC is a cornerstone in the management of OAM. TAC is a method in which the viscera
is protected while managing an open abdomen, allows expedited reexploration of the
abdomen in subsequent procedures, and can aid in preventing repeat damage to
abdominal fascia.8 As OAM has progressed and evolved so have methods of TAC.
Primary Skin Approximation

In an emergent setting, need for expeditious departure from operating room (OR) to
intensive care unit (ICU) for resuscitation, or in a resource poor setting, TAC can be
obtained by simply suturing closed the skin of the abdomen. Using towel clips to close
abdominal skin is another similar method. This is the simplest, oldest, and one of the
fastest forms of TAC but does have drawbacks. It should not be used in ACS and used
with caution in intra-abdominal sepsis. It does not aid in preventing fascial retraction. A
small single-center study has recently suggested similar clinical outcomes and com-
plications comparing simple whipstitch suture closure and ABTHERA Open Abdomen
Negative Pressure Therapy in the setting of blunt or penetrating trauma.9 This method
is also a cost saving and may be good option in a resource poor setting.
Silo or Bogota Bag

This method involves suturing a sterile plastic bag (can be a 3L saline bag) to the fascial
edges to achieve TAC. This is a cost-effective option for TAC. Because this method pro-
vides a tension-free closure, it will not aid in ease of fascial re-approximation. Additional
negative aspects of the silo or Bogota Bag are the inability to drain peritoneal fluid and it
has been linked to higher intestinal fistula rate.8 On the other hand, this method can be
an advantage when OAM is used for ACS and devitalized bowel is a concern because it
allows direct inspection of the bowel through the clear plastic.
Barker’s Vacuum Pack Method

Before current negative pressure wound therapy (NPWT) devices, this technique was
an inexpensive and easy to apply method of TAC. First described by Barker and col-
leagues in the 1990s, this method consists of applying a perforated polyethylene sheet
under the fascia, covering the viscera, followed by moist surgical towels, two 10F flat
silicone suction drains laid on the top of the towels, and covered with an adhesive
iodophor-impregnated drape.10 Drains are connected to continuous suction. This
technique can be performed with commonly used surgical materials and applied
quickly. Despite it being the original method of vacuum pack TAC, it has now been
replaced with newer and improved NPWT TAC devices.
Negative Pressure Wound Therapy

This is one of the most common TAC methods used in the United States.9,11 One example
of this is the ABTHERA Open Abdomen Negative Pressure Therapy (Figs. 2–4). This
method removes peritoneal fluid which can help to reduce bowel edema, provides nega-
tive pressure which can decrease fascial retraction, protects abdominal contents, and
Fig. 2. Plastic-covered inner portion of ABTHERA Open Abdomen Negative Pressure

Therapy.
can be applied and taken down quickly. Another benefit is the lack of fascial sutures
required for this method, so it decreases direct fascial injury in OAM. NPWT TAC has
been associated with higher rates of successful abdominal closure and decreased fistula
rates compared with non-NPWT methods in OAM for peritonitis or ACS.12,13 New data
Fig. 3. ABTHERA Open Abdomen Negative Pressure Therapy fully in place after exploratory
laparotomy.
6 Serfin et al
Fig. 4. ABTHERA Open Abdomen Negative Pressure Therapy after second look with reduce
skin separation.
are showing even better outcomes regarding fascial closure and decreased complica-
tions when NPWT is combined with fascial traction systems.11,14
Wittmann Patch
This is a method incorporates Velcro sheets that are sutured to the edges of the fascia to
help re-approximate the fascia. It is a fascial traction system that can aid in re-
approximating fascia in the setting of OAM. The patch can be peeled apart for abdominal
reentry, and as intra-abdominal swelling decreases, the patch can be re-approximated
tighter in a subsequent manner. There are other products/techniques similar to this
such as the abdominal re-approximation anchor (ABRA) or the vacuum and mesh-
mediated fascial traction, mesh-mediated fascial traction, and so forth. Many studies
have showed the benefits of combining the Wittmann patch (or ABRA) with NPWT
regarding successful fascial closure, reduced time to fascial closure, and reduced
complication rates.13–16 The idea is similar to serial placement of retention sutures to
aid in fascial closure without the downside of fascial trauma by repeatedly replacing
the sutures. In the newest practice management guidelines from the Eastern Association
for the Surgery of Trauma, there is a conditional recommendation to use fascial traction
systems combined with NPWT due to the improved rate of primary fascial closure without
worsening mortality or fistula formation.11
OPEN ABDOMEN MANAGEMENT IN THE ICU

Ongoing Resuscitation and Sepsis Control
The indication for OAM will help direct the postoperative ICU management. Despite the
inciting insult or injury, resuscitation and correction of physiologic abnormalities should
be top priority. Correcting the lethal triad of hypothermia, acidosis, and coagulopathy
should be first.17 Common end points for resuscitation should be used such as
improving vital signs, urine output goals, base deficit correction, and clearing of serum
lactate levels. Hypothermia can worsen both coagulopathy and acidosis. Increased
heat loss can be assumed in a patient with an open abdomen, so maintaining normo-
thermia is paramount. Coagulopathy should be corrected with blood products based
on laboratory values and or viscoelastic tests (thromboelastography [TEG] or rotational
thromboelastometry [ROTEM]). Acid–base deficits corrected with fluid resuscitation,
ventilator manipulation, and addressing the underlying cause. To continue broad spec-
trum antibiotics in the setting of intra-abdominal sepsis, the course will be dictated
based on source control and the specific clinical scenario. If OAM is for a non-sepsis
reason, then prophylactic antibiotics can be discontinued after 24 hours.18
Fluid Status
Fluid loss, electrolyte loss, and protein loss are dramatically increased in the setting of
OAM.19,20 Fluid resuscitation will be needed, but over resuscitation with fluids also
brings challenges such as bowel edema, increasing risk for ACS (yes, even in the
setting of an open abdomen with a TAC), volume overload, pulmonary edema, and
acute respiratory distress syndrome. Volume overload has been linked to decrease
in primary fascial closure rates along with its other known complications.17,19 The
goal of volume resuscitation is a balanced resuscitation to euvolemia with attempts
to minimize the sequela of volume overload.17–19 Diuresis has been proposed as a
way of decreasing bowel edema but the literature on this is mixed and no formal rec-
ommendations can be made at this time for this indication.11,17 The use of NPWT can
aid in decreasing bowel edema, and some devices like the ABTHERA can help monitor
peritoneal fluid losses for accurate measurements.12,13,18
Nutrition
It has already been discussed above that protein loss is a significant factor in the open
abdomen. During critical illness, the body enters a catabolic state. Nutritional support is
essential during this time. Traditional nitrogen balance calculations, which are the most
common way to determine protein requirements, do not account for protein loss from
the open abdomen.20 A study looking at abdominal fluid nitrogen and losses from an
open abdomen state determined that there is approximately 1.9 1.1 g of nitrogen
lost per liter of abdominal fluid.20 Another study estimates this loss at 2 to 4.6 g of nitro-
gen lost per liter of abdominal fluid depending on the type of TAC.17 Given this, nutri-
tional supplementation in the patient undergoing OAM is critical and has been shown
to improve the rates of abdominal closure and decrease complications associated
with the open abdomen. Enteral feeding, when appropriate given bowel continuity
and other clinical factors, is the optimal way for nutritional support in the setting of an
open abdomen and has been proven safe and beneficial. Immediate enteral feeding
in patients who underwent damage control laparotomy (DCL) had no effect on abdom-
inal closure rate and was associated with decrease in pneumonia rates.21 Early enteral
feeding in the setting of open abdomen is also associated with higher rates of earlier pri-
mary abdominal closure, lower fistula rates, lower hospital charges, and decreased
mortality.17,22,23 In 2012, the Western Trauma Association published a large multicenter
trial comparing OAM patients who received enteral nutrition versus patients kept nil per
os or nothing by mouth (NPO) before abdominal closure and found that the enteral nutri-
tion group had increased fascial closure rates, decreased mortality, and decreased
complication rates.23 Given these findings, nutritional support with enteral feedings is
strongly supported in the patient undergoing OAM when possible.
8 Serfin et al
Direct Peritoneal Resuscitation

Direct peritoneal resuscitation (DPR) is another developing technique used for resus-
citation of patients undergoing OAM. Even after the initial insult has been managed,
secondary injury from ischemic reperfusion injury (IRI) through various physiologic
mechanisms related to imbalances of vasoconstrictive to vasodilatory mediators
and loss of endothelial mechanisms to vasodilate occur.24 DPR with glucose-based
peritoneal dialysis (PD) solution is suspected to reduce and combat IRI secondary
to microvascular visceral vasoconstriction by increased vasodilation from adenosine
and nitric oxide release from glucose and its degradation product.24 This increase in
visceral blood flow is thought to decrease inflammatory mediators through improved
clearance of inflammatory mediators, and the hypertonicity of the PD solution could
help reduce intra-abdominal edema. The Eastern Association for the Surgery of
Trauma’s systematic review with meta-analysis and practice guidelines on manage-
ment of the open abdomen addresses DPR and the three leading studies for DPR
by Smith and colleagues. Although results are compelling for improved primary
closure rates as well as other benefits, more independent studies are needed to pro-
vide further support of this strategy.11,25–27 The studies by Smith and colleagues
demonstrated increase in primary fascial closure rates for OAM patients undergoing
DPR as well as decreased intra-abdominal complications from OAM (likely due to
time to fascial closure), improved visceral blood flow, and reduction in circulating in-
flammatory cytokines but mentions that there was no difference in volume of resusci-
tation in first 24 hours, no difference in injury severity score, and no difference in
morbidity or mortality.24–27 Another article published in the Surgical Infections journal
in 2022 retrospectively analyzed patients undergoing DCL and DPR versus DCL
without DPR and concluded that infection complications and mechanical failure of
the closure technique were similar in the two groups and the DPR 1 patients had a
longer time to final closure.28 DPR should be used with hesitancy until more indepen-
dent studies and conclusive data are available.11
RISKS OF OPEN ABDOMEN MANAGEMENT
We have described above many potential risks and sequelae of the open abdomen,
such as fluid losses, electrolyte imbalances, increased nutritional need, and infection.
Some more challenging risks and complications include fistulas and loss of domain in
patients undergoing OAM. Early closure of the abdominal wall and fascia is the most
effective way to reduce complications of the open abdomen.
Loss of Domain
Throughout the duration of the open abdomen, the fascia of the abdominal wall re-
tracts laterally, making primary closure significantly more difficult as time goes on.
Traditional OAM was with planned ventral hernia formation and delayed abdominal
wall reconstruction.16 Since then, with the progression of better TAC techniques
and more effective ways to optimize patients for earlier primary closure, this traditional
method is becoming less common. The best way to prevent loss of domain is earlier
closure of the abdominal fascia. As discussed above, the use of newer TACs such as
NPWT, Wittmann patch, other dynamic fascial traction techniques, or combination of
these, will aid in earlier closure of the abdomen.
Fistulas
Fistula formation in the setting of OAM is one of the more serious complications due to
their difficulty to control and repair.19 No method of TAC has been independently
associated with decrease in fistula formation.11 TAC with NPWT has been shown to
decrease fistula formation rate by reducing the time to primary fascial closure.12,13
The only way to definitively decrease fistula formation is closure of the abdominal
wall as soon as it can be safely done. If a fistula does form, this can complicate
abdominal wall reconstruction in the future. Traditional fistula management should
be trialed to aid in spontaneous closure before abdominal wall reconstruction. If the
fistula persists, timing of fistula takedown with concomitant or delayed abdominal
wall reconstruction will need to be well planned.
TIMING OF TAKE BACK TO OR
The timing of taking a patient back to the OR for a second-look operation varies in each
unique surgical scenario. It is recommended that the patient is resuscitated in the ICU
before returning to the OR and is usually recommended to occur between 24 and
72 hours after initial operation.8 Generally though, return to the OR should ideally take
place between 24 and 48 hours. There is a delicate balance between making sure
that the patient is adequately resuscitated to safely return to the OR while also limiting
the amount of time between surgeries to decrease OAM complications. The patient may
need to be taken back multiple times depending on the clinical scenario, but the goal of
each operation includes progressing toward definitive closure of the abdomen.
CLOSURE OF THE OPEN ABDOMEN
Once ongoing resuscitation efforts are complete and the cause of OAM has been
addressed, early fascial and abdominal closure should be the next strategy of man-
agement.8 Primary fascial closure is the ideal option. If this is not possible, there is
high tension of the fascia when brought together, or there is concern for development
of intra-abdominal hypertension/ACS, then delayed closure of the fascia leading to ex-
pected ventral hernia can be considered.
Closure Without Mesh
In some circumstances, if the fascia cannot be approximated after OAM, then planned
granulation followed by skin grafting may be required to cover intra-abdominal con-
tents until definitive abdominal wall reconstruction is possible. Another option is the
use of hydrocolloid dressings which can be a simple, effective, and cost-efficient
choice for management and coverage of long-term open abdomen patients.29 Before
abdominal wall reconstruction, it is recommended to obtain a CT scan for preopera-
tive planning. Abdominal wall reconstruction options include modified Rives-Stoppa
technique, component release procedures, transversus abdominis release technique,
or combination techniques.
Closure with Mesh
There are positive benefits to mesh use at the time of initial laparotomy closure for high-
risk hernia patients. The PRImary Mesh closure of Abdominal midline wounds (PRIMA)
trial was an international, double-blinded randomized controlled trial comparing onlay
reinforcement, sublay reinforcement, and primary suture after midline laparotomy and
found that onlay mesh reinforcement had a significant reduction in hernia prevention
as well as no increase in surgical site infection.30 A 2-year follow-up study of the PRIMA
trial published in 2017 showed a significant reduction in incisional hernias with onlay
mesh reinforcement compared with sublay mesh reinforcement and primary suture
only.31 In regard to hernia repair after OAM, data are very limited on prophylactic
mesh use during delayed primary fascial closure. A small trial of 10 patients looking
10 Serfin et al
at prophylactic onlay mesh (of either long-term absorbable alloplastic or nonabsorbable

mesh) implantation during definitive fascial closure after open abdomen therapy
showed promising results with no hernia formation at 12.4 10.8 months.32 Again,
the data for mesh use at the time of closure after OAM are very limited and need further
studies before more official recommendations can be made.
CONCLUSION AND RECOMMENDATIONS
The management of the open abdomen is a tool that all general and trauma surgeons
should have in their armamentarium as all will encounter patients who require DCL and
OAM. As technology and understanding continue to advance, the domain of open
abdominal management will continue to evolve. Early fascial closure, when appro-
priate, is always the goal. When this is not possible, NPWT is the preferred method
of management given decreased trauma to fascial edges and decreased fistula forma-
tion until definitive abdominal closure can be accomplished.
CLINIC CARE POINTS
Use open abdomen management (OAM) when patient is too unstable for completion of
surgery, needs a second look, or is anatomically unable to be closed at the time of index
operation.
Chose the technique of OAM that is best for the patient with the resources available of your
institution.
Plan final abdominal closure to provide the best opportunity for closure with lowest risk of
ventral hernia when possible.
DISCLOSURE
The authors have nothing to disclose.
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Damage Control Laparotomy and Management of The Open Abdomen

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D a m a g e C o n t ro l L a p a ro t o m y

INTRODUCTION AND HISTORY OF THE OPEN ABDOMEN

Surg Clin N Am - (2023) -–-

Intra-Abdominal Hypertension/Abdominal Compartment Syndrome

updated by the World Society of the Abdominal Compartment Syndrome. In their

Damage Control Laparotomy

Fig. 1. Open abdomen with omentum covering majority of bowel.

TYPES OF TEMPORARY ABDOMINAL CLOSURE FOR OPEN ABDOMEN

Primary Skin Approximation

Silo or Bogota Bag

Barker’s Vacuum Pack Method

Negative Pressure Wound Therapy

Fig. 2. Plastic-covered inner portion of ABTHERA Open Abdomen Negative Pressure

OPEN ABDOMEN MANAGEMENT IN THE ICU

Direct Peritoneal Resuscitation

RISKS OF OPEN ABDOMEN MANAGEMENT

TIMING OF TAKE BACK TO OR

CLOSURE OF THE OPEN ABDOMEN

at prophylactic onlay mesh (of either long-term absorbable alloplastic or nonabsorbable

CONCLUSION AND RECOMMENDATIONS

CLINIC CARE POINTS

The authors have nothing to disclose.

1. Ogilvie WH. The late complications of abdominal war-wounds. Lancet 1940;

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