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The management of laparotomy wounds using the open abdomen (OA) technique represents a life-saving strategy of last resort in carefully selected clinical scenarios. The concept was first described by William Heneage Ogilvie in the context of war-related abdominal injuries []. Since its initial description, the OA technique has undergone substantial evolution and has remained the subject of ongoing debate. In contemporary practice, however, it is widely accepted as a valid therapeutic approach when applied according to well-defined indications. In 2018, the World Society of Emergency Surgery (WSES) published recommendations for the management of critically ill patients undergoing damage control surgery (DCS) []. Both traumatic and non-traumatic patients with severe intra-abdominal pathology are at high risk of developing septic complications, intra-abdominal hypertension (IAH), and abdominal compartment syndrome (ACS), which may ultimately progress to multiple organ failure (MOF). In this setting, the OA approach may represent the only viable option, particularly in the presence of severe visceral edema preventing primary fascial closure, while also allowing effective source control and facilitating planned re-explorations.

The implementation of DCS and OA strategies has been associated with improved survival in a highly selected population of critically ill patients with hemodynamic instability due to trauma, abdominal sepsis, severe acute pancreatitis, or major vascular events. Although overall mortality in this group remains high (approximately 19–41%), these approaches are considered to improve survival relative to otherwise expected fatal outcomes [, ]. A common underlying pathophysiological mechanism is that aggressive fluid resuscitation can cause capillary leakage leading to visceral edema and increased intra-abdominal pressure [, ]. Goal-directed fluid therapy may consequently contribute to a reduction in IAH; therefore, a restrictive fluid strategy should be considered where clinically feasible []. However, despite its life-saving potential, OA is associated with considerable morbidity, including enteroatmospheric fistula (EAF), loss of abdominal domain, complex ventral hernia formation, prolonged intensive care unit (ICU) course, frozen abdomen, infectious complications, and significant fluid and protein losses [].

Despite advances in temporary abdominal closure (TAC) techniques and perioperative critical care, achieving early fascial closure while minimizing complications remains a major clinical challenge. Moreover, the available evidence is largely heterogeneous and predominantly observational. Therefore, this narrative review aims to critically appraise current evidence on the indications, management strategies, and outcomes associated with the OA technique in patients undergoing DCS.

Intra-Abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are key conditions in patients requiring OA management. According to the updated World Society of the Abdominal Compartment Syndrome (WSACS) guidelines, intra-abdominal pressure (IAP) is typically measured via the bladder []. IAH is defined as a sustained IAP ≥ 12 mmHg and is graded as follows: Grade I (12–15 mmHg), Grade II (16–20 mmHg), Grade III (21–25 mmHg), and Grade IV (> 25 mmHg). ACS is defined as a sustained IAP > 20 mmHg associated with new organ dysfunction. ACS is further classified as primary (intra-abdominal origin), secondary (extra-abdominal origin), or recurrent. Early recognition of IAH/ACS is essential for timely intervention, including decompressive laparotomy and OA management [].

The increasing incidence of IAH, which may frequently progress to ACS, has necessitated the formulation of internationally accepted definitions, management strategies, and a standardized classification system to guide clinical practice. The need for an OA classification system arose from several considerations, including the standardization of clinical status, the harmonization of therapeutic recommendations for OA management, and the ability to compare outcomes among specialized research groups investigating this condition []. As a result of these efforts, the first comprehensive classification system for patients managed with the OA technique was introduced in 2009. Subsequently, in 2016, the original classification was revised and updated by a group of authors led by Michael Björck, resulting in a modified classification system that is currently widely adopted in clinical practice (Table ) [].

Indications for the OA technique can be broadly categorized as physiological, anatomical, and logistical. Physiological indications include situations such as hemodynamic instability requiring emergent laparotomy within the framework of DCS. Anatomical indications arise when primary abdominal closure is not feasible due to loss of abdominal wall soft tissue, most commonly in the setting of trauma or severe intra-abdominal sepsis, or when there is a high risk of developing ACS []. Logistical indications refer to clinical situations in which a planned re-exploration ( second-look laparotomy ) is anticipated. In general, the indications for the OA technique can be divided into two principal groups: those related to traumatic and those related to non-traumatic patients (Table ) []. The relative frequency of these indications exhibits significant regional variation: in North American cohorts, peritonitis (38.7%) and trauma - gunshot and stab wounds − (34.7%) had a similar distribution, while in the European and the Asiatic continent prevailed peritonitis [].

Furthermore, the WSACS reports that while ACS complicates roughly 5–15% of major trauma cases, its incidence may reach 30% in non-traumatic populations requiring massive fluid resuscitation for septic shock []. This regional refinement is clinically significant, as non-traumatic patients typically demonstrate lower primary fascial closure rates and increased morbidity compared to their traumatic counterparts.

The primary goal of surgical management using the OA technique is to achieve definitive fascial and abdominal wall closure. This objective must be pursued while simultaneously addressing the risk of developing ACS and septic complications, the most significant of which is the formation of an EAF [, ]. In emergency surgery, midline laparotomy (a long vertical incision along the linea alba) remains the most commonly used surgical approach, primarily due to its rapid execution and technical simplicity (Fig. ). In cases of established ACS, decompressive laparotomy has demonstrated high effectiveness in reducing IAP []. However, laparotomy in the setting of an OA is associated with a significant risk of EAF formation, reported in an incidence of approximately 5–25% of patients depending on underlying pathology and management strategy, as well as a relatively frequent failure to achieve definitive fascial closure (DFC) [, ]. These limitations have stimulated the search for alternative operative approaches.

One promising alternative is transverse laparotomy, the effectiveness of which has been reported in several recent studies (Fig. ). The procedure requires the same surgical instrumentation and can be performed with only slightly longer operative time compared with midline laparotomy. Importantly, the general principles of OA management remain identical regardless of whether a midline or transverse incision is used.

In emergency surgical practice, transverse laparotomy in the setting of OA has shown particular benefit in the treatment of severe acute pancreatitis []. Increasing evidence also suggests that a transverse abdominal incision may provide improved rates of abdominal closure in patients with septic peritonitis. In both clinical conditions, however, delayed fascial closure remains a major challenge. The lower rate of fascial dehiscence and complications associated with transverse laparotomy is thought to result from the thicker tissue coverage and improved vascularization of the lateral abdominal wall []. Moreover, the physiological orientation of the incision preserves the integrity of the rectus abdominis muscles while leaving the linea alba intact. This significantly reduces fascial retraction, which represents the primary obstacle to successful delayed fascial closure. Nevertheless, midline laparotomy continues to offer advantages in terms of shorter operative times and easier extension of the incision when wider abdominal exposure is required [].

A wide spectrum of TAC techniques is currently used in clinical practice. Among these, methods utilizing NPWT are generally considered the most effective. In contrast, passive techniques without negative pressure, such as the Bogotá bag , should be reserved mainly for situations with limited material resources [, ]. A specific technique historically used in OA management is skin-only closure, in which the skin is closed while the fascia remains open. This method was removed from official recommendations by the WSES in 2018 due to several disadvantages, including the inability to control intra-abdominal fluid drainage, interference with radiological imaging, and a high incidence of ACS, evisceration, and skin-related complications. Despite these concerns, the technique has recently regained some attention, particularly in the context of military surgery and extreme emergency scenarios. Skin-only closure is extremely rapid, inexpensive, and widely available, allowing rapid reduction of heat and fluid loss. In critically ill hemodynamically unstable patients, the procedure can therefore be completed within a very short time interval, which represents its main advantage when rapid termination of life-saving laparotomy is required [].

In the management of OA, the surgeon’s primary effort should focus on achieving early DFC while preventing the development of EAF. A key strategy to prevent progression toward the so-called frozen abdomen is the reduction of adhesion formation between intestinal loops and the abdominal wall, together with prevention of fascial retraction. These objectives are effectively addressed by NPWT combined with dynamic fascial traction using a mesh, a technique first described in 2007 []. The principle of this method involves placement of a specialized anti-adhesive visceral protective layer that separates the abdominal viscera from the abdominal wall. This interface not only mechanically prevents adhesion formation but is also essential for maintaining bowel wall integrity and mitigating the risk of EAF formation [, ]. At the same time, a polypropylene mesh is sutured to the fascial edges to counteract the lateral traction forces of the abdominal wall musculature and prevent progressive fascial retraction.

The main advantages of polypropylene mesh traction include its high mechanical resistance to traction forces, the possibility of repeated abdominal re-exploration, and the gradual approximation of fascial edges during subsequent surgical revisions. Unlike absorbable materials such as Vicryl mesh, which provide only temporary stabilization and are prone to loss of tensile strength in the presence of enzymatic degradation, the non-absorbable nature of polypropylene allows for sustained tension []. The combination of NPWT with dynamic fascial traction has demonstrated the highest success rates in achieving delayed fascial and is currently recommended as the preferred TAC technique, even in cases of septic peritonitis or severe intra-abdominal contamination []. A refined and widely adopted iteration of this approach is Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction (VAWCM).

The VAWCM technique integrates the benefits of negative pressure with a mechanical mechanical tension system. In this procedure, a temporary prosthetic mesh (typically polypropylene) is sutured to the fascial edges and used as a bridge. The NPWT system is then applied over the mesh. During subsequent surgical re-explorations, the mesh is incised in the midline, the abdomen is washed, and the mesh is re-tightened by suturing it back together, effectively pulling the fascial edges toward the midline. Clinical data indicate that this combined approach achieves DFC rates ranging from 77% to 100% [, ]. It should be emphasized that NPWT used alone, without the addition of a dynamic traction component, is associated with significantly lower closure rates—often reported between 18% and 59% and a prolonged interval to achieving definitive closure. This disparity is primarily attributed to the inability of standalone NPWT to counteract the lateral retraction of the fascial edges [, ]. VAWCM effectively mitigates these risks by providing constant, adjustable medial tension while simultaneously managing peritoneal exudate and reducing visceral edema via negative pressure.

Successful management of the OA is time-dependent and requires early transition from decompression to active fascial traction. Dynamic fascial traction should be initiated during the index operation or, at the latest, within the first 24–48 h. In hemodynamically stabilized patients, early traction—using either mesh-mediated (horizontal) or vertical systems—should be applied promptly to prevent lateral fascial retraction. Delayed initiation (> 48 h) is associated with increased risk of fascial fixation, loss of abdominal domain, and development of a frozen abdomen []. Management should follow a structured, stepwise approach. After initial decompression and source control, with adequate visceral protection, early fascial traction must be established. This strategy utilizes the residual elasticity of the abdominal wall before the onset of inflammation-related fibrosis. Techniques such as VAWCM or vertical traction systems (e.g., Fasciotens ® ) are recommended to maintain fascial approximation and preserve the potential for definitive closure [, ]. Planned re-explorations should be performed at 24–48-hour intervals, with progressive adjustment of traction as visceral edema decreases. Continuous, controlled tension facilitates fascial medialization through stress relaxation and tissue creep, thereby preserving abdominal domain and reducing the need for complex reconstructive procedures.

Definitive fascial closure should be achieved as early as clinically feasible, ideally within 5–7 days []. Prolonged OA duration is associated with increased risk of EAF formation and infectious complications. Early, dynamic fascial traction is therefore a key component of contemporary OA management aimed at minimizing morbidity [].

In the contemporary management of patients treated with the OA technique, increasing emphasis is placed on the benefits of early enteral nutrition (EN). However, it must be emphasized that the current evidence base remains limited and is largely derived from older literature. Furthermore, many existing studies address critically ill ICU patients in general rather than specifically those with an open abdomen; nevertheless, these findings appear largely transferable to the OA population when interpreted alongside the ESPEN guidelines on clinical nutrition in the ICU and surgery []. Notably, in critically ill patients with OA/NPWT, the use of enteral feeding within 7 days after surgery has been associated with better clinical outcomes []. According to current recommendations, enteral feeding should be initiated as soon as hemodynamic stability has been achieved, and adequate visceral perfusion has been ensured. A fundamental prerequisite is the presence of a viable and functional gastrointestinal tract, while a residual small bowel length of less than 75 cm is generally considered a relative contraindication to enteral feeding [].

Whenever feasible, placement of a nasojejunal feeding tube during the initial surgical procedure is recommended. If insertion is not possible due to significant edema or obstruction of the duodenum, the creation of a feeding jejunostomy may represent an appropriate alternative. Initiation of EN within the first 24–48 h has been shown to significantly improve wound healing, accelerate the achievement of DFC, and mitigate the hypercatabolic state while preserving the integrity of the intestinal mucosal barrier [, ]. In addition, early enteral feeding reduces the incidence of nosocomial pneumonia, decreases the risk of developing EAF, and ultimately shortens the length of hospital stay, thereby reducing overall treatment costs [, ]. Compared with total parenteral nutrition (TPN), early EN significantly lowers the risk of septic complications, which is particularly important in patients with abdominal trauma or concomitant traumatic brain injury []. Prolonged TPN has been associated with intestinal mucosal atrophy, increased bacterial translocation, and progressive intestinal wall edema, all of which may increase the risk of EAF formation []. For this reason, TPN should generally be reserved for selected situations such as intestinal malabsorption or the presence of a high-output intestinal fistula.

Recent evidence also suggests that EN in patients with OA may contribute to improved lymphatic flow, enhanced venous return, and reduction of visceral edema. Clinical outcomes strongly support this approach, as patients receiving early enteral feeding achieve rates of primary abdominal wall closure of up to 74%, compared with approximately 49% in patients in whom nutritional support is initiated later [].

In cases of prolonged OA management where primary fascial closure cannot be achieved due to significant fascial retraction, a strategy of planned ventral hernia is often adopted. In patients with persistent visceral edema, TAC devices are typically removed after approximately 2–3 weeks. The primary objective during this phase is protection of the intra-abdominal organs, achieved either through skin closure or by promoting granulation tissue formation followed by coverage with split-thickness skin grafts. Definitive abdominal wall reconstruction is performed in a delayed manner, usually 6–12 months later, when inflammatory adhesions have subsided and tissue conditions have stabilized []. Surgical repair techniques are generally selected according to the condition of the skin envelope. When adequate skin coverage and mobility are preserved, reconstruction may be achieved through bridging mesh repair or the use of the component separation technique (CST) (Fig. ). The fundamental principle of CST involves mobilization of the musculo-fascial components of the abdominal wall, particularly the rectus abdominis complex, allowing restoration of the midline. Component separation can be performed via anterior or posterior approaches, including the transversus abdominis release (TAR) technique, and these procedures are frequently combined with prosthetic mesh reinforcement [].

The choice of mesh material plays a critical role regarding the risk of infection and hernia recurrence. Synthetic meshes are generally preferred due to their superior mechanical strength and cost-effectiveness. Current evidence suggests that mesh porosity and weight are key determinants of successful tissue integration, with macroporous, medium-weight meshes demonstrating the most favorable balance between durability and resistance to infection []. In contaminated surgical fields, synthetic absorbable meshes such as Vicryl or Dexon were historically proposed. However, their rapid degradation within approximately 1–3 months has been associated with unacceptably high recurrence rates. To overcome these limitations, biosynthetic meshes such as GORE BIO-A and Phasix have been developed. These materials degrade more slowly, typically over six months or longer—providing prolonged structural support while potentially reducing infection risk and postoperative pain []. Biologic meshes, initially introduced with the expectation of improved performance in contaminated environments, have produced inconsistent results when compared with synthetic materials. Studies, including those by Johannes Atema and colleagues, report significantly higher hernia recurrence rates with biologic meshes, reaching approximately 30%, compared with roughly 7% for synthetic meshes [].

In cases involving extensive abdominal wall defects with unstable or absent skin coverage, advanced reconstructive techniques may be required. In specialized centers, microvascular free flap reconstruction using the tensor fasciae latae muscle (TFL) has emerged as a valuable option. However, this procedure requires close multidisciplinary collaboration between abdominal and plastic surgeons and is generally reserved for complex cases managed in highly specialized surgical centers [].

The management of the OA has undergone a substantial transformation over the past decade, evolving from a technique of “last resort” to a highly standardized component of modern emergency surgery. A key historical milestone was the establishment of definitions for IAH and ACS by the WSES in 2013, building upon earlier consensus statements of the Abdominal Compartment Society []. These standardized terminological frameworks subsequently enabled the development of evidence-based international recommendations published in 2018, which today form the cornerstone of management algorithms for both traumatic and non-traumatic critically ill patients [].

Historically, much of the evidence supporting the effectiveness of OA management was derived from relatively small and heterogeneous patient cohorts with inconsistent methodological quality. This limitation created a clear need for a robust international data source. In response, the WSES, in collaboration with the Panamerican Trauma Society, launched the International Register of Open Abdomen (IROA) in 2015. This prospective cohort registry collects data on patient demographics, comorbidities, TAC techniques, and OA-specific complications. Data derived from this large-scale collaborative project suggest that, when utilized within appropriate clinical indications, the OA technique is associated with favorable survival trends in patients undergoing DCS. Preliminary analyses indicate that the observed mortality rate in the IROA cohort is approximately 29.7%, which is notably lower than the rates traditionally anticipated for such critically ill populations []. However, it is essential to emphasize that these findings represent a clinical association rather than a direct causal reduction in mortality. The reported effectiveness of the OA strategy is significantly influenced by patient selection and the underlying etiology, with traumatic indications generally demonstrating lower mortality compared to non-traumatic, septic cases.

However, geographical analysis of IROA data published in 2023 revealed substantial differences in survival outcomes between continents. While North American and European centers reported comparable treatment durations and relatively lower mortality rates, outcomes in several Asian regions were notably poorer, with mortality exceeding 40%. These discrepancies reflect not only differences in surgical technique but also variations in health-care infrastructure, intensive care availability, and regional differences in indication criteria for OA [].