Abdominal Trauma

Coccolini et al.
World Journal of Emergency Surgery (2018) 13:7

DOI 10.1186/s13017-018-0167-4
REVIEW Open Access
The open abdomen in trauma and

non-trauma patients: WSES guidelines
Federico Coccolini1*, Derek Roberts2, Luca Ansaloni1, Rao Ivatury3, Emiliano Gamberini4, Yoram Kluger5,
Ernest E. Moore6, Raul Coimbra7, Andrew W. Kirkpatrick2, Bruno M. Pereira8, Giulia Montori1, Marco Ceresoli1,
Fikri M. Abu-Zidan9, Massimo Sartelli10, George Velmahos11, Gustavo Pereira Fraga8, Ari Leppaniemi12,
Matti Tolonen12, Joseph Galante13, Tarek Razek14, Ron Maier15, Miklosh Bala16, Boris Sakakushev17,
Vladimir Khokha18, Manu Malbrain19, Vanni Agnoletti4, Andrew Peitzman20, Zaza Demetrashvili21, Michael Sugrue22,
Salomone Di Saverio23, Ingo Martzi24, Kjetil Soreide25,26, Walter Biffl27, Paula Ferrada3, Neil Parry28,
Philippe Montravers29, Rita Maria Melotti30, Francesco Salvetti1, Tino M. Valetti31, Thomas Scalea32,
Osvaldo Chiara33, Stefania Cimbanassi33, Jeffry L. Kashuk34, Martha Larrea35, Juan Alberto Martinez Hernandez36,
Heng-Fu Lin37, Mircea Chirica38, Catherine Arvieux38, Camilla Bing39, Tal Horer40, Belinda De Simone41,
Peter Masiakos42, Viktor Reva43, Nicola DeAngelis44, Kaoru Kike45, Zsolt J. Balogh46, Paola Fugazzola1,
Matteo Tomasoni1, Rifat Latifi47, Noel Naidoo48, Dieter Weber49, Lauri Handolin50, Kenji Inaba51, Andreas Hecker52,
Yuan Kuo-Ching53, Carlos A. Ordoñez54, Sandro Rizoli55, Carlos Augusto Gomes56, Marc De Moya57, Imtiaz Wani58,
Alain Chichom Mefire59, Ken Boffard60, Lena Napolitano61 and Fausto Catena62
Abstract
Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment
syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements
and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical
situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of
infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated
damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma
patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries
or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming
and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be
considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the
patient can physiologically tolerate it. All precautions to minimize complications should be implemented.
Keywords: Open abdomen, Laparostomy, Non-trauma, Trauma, Peritonitis, Pancreatitis, Vascular emergencies,
Intra-abdominal infection, Fistula, Nutrition, Re-exploration, Reintervention, Closure, Biological, Synthetic, Mesh,
Technique, Timing, Guidelines
* Correspondence: federico.coccolini@gmail.com
1
General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni
Ghirotti, 286, 47521 Cesena, Italy
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Coccolini et al. World Journal of Emergency Surgery (2018) 13:7 Page 2 of 16
Background using OA. It should not be performed liberally. Measures

Damage control management (DCM) of severely injured to mitigate complications are necessary. In all patients
or physiologically deranged patients is considered by many with an OA, every effort should be exerted to achieve
to consist of damage control resuscitation (DCR) and primary fascial closure (i.e., fascia-to-fascia closure of the
damage control surgery (DCS). Use of DCM in patients abdominal wall within the index hospitalization) as soon
with deranged physiology may trigger intra-abdominal as the patient can physiologically tolerate it [3].
hypertension (IAH) or abdominal compartment syndrome
(ACS) that may aggravate physiologic derangement or Purpose and use of this guideline
multiorgan failure (MOF) in a vicious circle unless The guidelines are evidence-based, with the grades of
interrupted by abdominal decompression (surgical or recommendation, based on the evidence. These guide-
other) [1, 2]. Further, in other clinical situations, the abdo- lines present methods for optimal management of open
men cannot be closed due to visceral edema, the inability abdomen in trauma and non-trauma patients. They do
to completely control the compelling source of infection not represent a standard of practice. They are suggested
or to the necessity to re-explore (in a “planned re-look plans of care, based on best available evidence and a
laparotomy”) or to complete DCS procedures or in cases consensus of experts. They, however, do not exclude
of abdominal wall damage. Although open abdomen (OA) other approaches as being within a standard of practice.
has been proposed to be effective in preventing or treating For example, they should not be used to compel adher-
deranged physiology in patients with severe injuries or ence to a given method of medical management, which
critical illness, it must be recognized as a non-anatomic should be finally determined after taking into account
situation that has potential for severe side effects while conditions at the relevant medical institution (staff
increasing resource utilization [3]. levels, experience, equipment, etc.) and the characteristics
The World Society for Emergency Surgery (WSES) of the individual patient. The responsibility for the results,
accepted the definitions of IAH, ACS, and related however, rests with the engaging practitioners and not
conditions published by the World Society Abdominal aged therein, and not the consensus group.
Compartment Syndrome in 2013 (WSACS) [2–4] (Fig. 1).
OA management consists of intentionally leaving the Methods
abdominal fascial edges of the paired rectus abdominus A computerized search was performed in MEDLINE,
muscles un-approximated (laparostomy) in order to EMBASE, and Scopus by an information scientist/librarian
truncate operation, prevent IAH/ACS, and facilitate for the time range of January 1980 to August 2017. The
re-exploration without damaging the abdominal fascia [3]. terms open abdomen, laparostomy, injuries, trauma,
Temporary abdominal closure (TAC) refers to the method peritonitis, pancreatitis, vascular, ischemia, resuscitation,
for providing protection to the abdominal viscera during the adult, management, infection, intensive care unit, anasto-
time the fascia remains open [2, 5]. Patients undergoing OA mosis, vasopressors, and follow-up in various combinations
management are at risk of developing entero-atmospheric with the use of the Boolean operators “AND” and “OR”
fistula (EAF) and a “frozen abdomen,” intra-abdominal were used. No search restrictions were imposed. The dates
abscesses, and lower rates of definitive fascial closure were selected to allow comprehensive published abstracts
[6, 7]. The risk-benefit ratio must be kept in mind in of clinical trials, consensus conferences, comparative
studies, congresses, guidelines, government publications,
multicenter studies, systematic reviews, meta-analyses, large
case series, original articles, and randomized controlled
IAH grade IAP [mmHg] trials. Case reports and small case series were excluded. We
also analyzed the reference lists of relevant narrative review
Grade I 12 - 15 articles identified during the search to identify any studies
that may have been missed.
Grade II 16 - 20 For each article, we subsequently applied a level of
evidence (LE) using the Grading of Recommendations,
Grade III 21 - 25 Assessment, Development, and Evaluation (GRADE) system
[8] (Table 1). The full GRADE process was not used, as this
Grade IV > 25 system is difficult to apply when scant evidence exists. A
group of experts in the field of OA management, coordi-
> 20 with new organ
ACS disfunction/failure nated by a central coordinator, were subsequently convened
in order to elicit their evidence-based opinions on certain
Fig. 1 WSACS grading of intra-abdominal hypertension (IAH) (IAP
key clinical questions relating to the OA. Through a Delphi
intra-abdominal pressure, ACS abdominal compartment syndrome) [4]
process, the clinical questions were discussed in rounds.
Table 1 GRADE system to evaluate the level of evidence and recommendation

Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications
1A
Strong recommendation, Benefits clearly outweigh risk RCTs without important limitations Strong recommendation, applies
high-quality evidence and burdens, or vice versa or overwhelming evidence from to most patients in most
observational studies circumstances without reservation
1B
Strong recommendation, Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, applies
moderate-quality evidence and burdens, or vice versa (inconsistent results, methodological to most patients in most
flaws, indirect analyses, or imprecise circumstances without reservation
conclusions) or exceptionally strong
evidence from observational studies
1C
Strong recommendation, Benefits clearly outweigh risk Observational studies or case series Strong recommendation but
low-quality or very and burdens, or vice versa subject to change when higher
low-quality evidence quality evidence becomes available
2A
Weak recommendation, Benefits closely balanced with RCTs without important limitations Weak recommendation, best
high-quality evidence risks and burden or overwhelming evidence from action may differ depending on
observational studies the patient, treatment
circumstances, or social values
2B
Weak recommendation, Benefits closely balanced with RCTs with important limitations Weak recommendation, best
moderate-quality evidence risks and burden (inconsistent results, methodological action may differ depending on
flaws, indirect, or imprecise) or the patient, treatment
exceptionally strong evidence circumstances, or social values
from observational studies
2C
Weak recommendation, Uncertainty in the estimates of Observational studies or case series Very weak recommendation;
low-quality or very benefits, risks, and burden; benefits, alternative treatments may
low-quality evidence risk, and burden may be be equally reasonable and
closely balanced merit consideration
The central coordinator assembled the different answers abdominal wall tissue loss and aggressive resuscitation
derived from each round. Each version was then revised are predictors of the necessity for open abdomen in
and improved through iterative evaluation. The final version trauma patients (Grade 2B)
about which the agreement was reached resulted in the
comments and recommendations made in the present
guideline. Statements have been summarized in Table 2. Decompressive laparotomy is indicated in abdominal
compartment syndrome if medical treatment has
Indications failed after repeated and reliable IAP measurements
Trauma patients (Grade 2B)
Persistent hypotension, acidosis (pH <7.2),

hypothermia (temperature < 34°C) and coagulopathy The inability to definitively control the source of
are strong predictors of the need for abbreviated contamination or the necessity to evaluate bowel
laparotomy and open abdomen in trauma patients perfusion may be an indicator to leave the
(Grade 2A) abdomen open in post-traumatic bowel injuries
(Grade 2B)
Risk factors for abdominal compartment syndrome Severely injured patients with hemodynamic instability
such as damage control surgery, injuries requiring are at higher risk of ACS for several reasons (i.e., aggressive
packing and planned reoperation, extreme visceral or resuscitation, ischemia-reperfusion injury, visceral or
retroperitoneal swelling, obesity, elevated bladder retroperitoneal swelling, recurrent bleeding, and intra-
pressure when abdominal closure is attempted, peritoneal packing) [9–12].
Table 2 Summary of statements

Statements
Indications
Trauma patients Persistent hypotension, acidosis (pH <7.2), hypothermia (temperature < 34°C) and coagulopathy are strong
predictors of the need for abbreviated laparotomy and open abdomen in trauma patients (Grade 2A)
Risk factors for abdominal compartment syndrome such as damage control surgery, injuries requiring packing
and planned reoperation, extreme visceral or retroperitoneal swelling, obesity, elevated bladder pressure when
abdominal closure is attempted, abdominal wall tissue loss and aggressive resuscitation are predictors of the
necessity for open abdomen in trauma patients (Grade 2B)
Decompressive laparotomy is indicated in abdominal compartment syndrome if medical treatment has failed
after repeated and reliable IAP measurements (Grade 2B)
The inability to definitively control the source of contamination or the necessity to evaluate the bowel
perfusion may be an indicator to leave the abdomen open in post-traumatic bowel injuries (Grade 2B)
Non-trauma patients Decompressive laparotomy is indicated in abdominal compartment syndrome if medical treatment has failed
after repeated and reliable IAP measurements (Grade 2B)
➢ Peritonitis The open abdomen is an option for emergency surgery patients with severe peritonitis and severe sepsis/septic
shock under the following circumstances: abbreviated laparotomy due to the severe physiological derangement,
the need for a deferred intestinal anastomosis, a planned second look for intestinal ischemia, persistent source of
peritonitis (failure of source control), or extensive visceral oedema with the concern for development of abdominal
compartment syndrome (Grade 2C).
➢ Vascular emergencies The open abdomen should be considered following management of hemorrhagic vascular catastrophes such
as ruptured abdominal aortic aneurysm (Grade 1C)
The open abdomen should be considered following surgical management of acute mesenteric ischemic insults (Grade 2C).
➢ Pancreatitis In patients with severe acute pancreatitis unresponsive to step-up conservative management surgical decompression
and open abdomen open are effective in treating abdominal compartment syndrome (Grade 2C)
Leaving the abdomen open after surgical necrosectomy for infected pancreatic necrosis is not recommended
except in those situations with high risk factors to develop abdominal compartment syndrome (Grade 1C)
Management
Trauma and non-trauma patients The role of Damage Control Resuscitation in OA management is fundamental and may influence outcome (Grade 2A)
ICU management A multidisciplinary approach is encouraged, especially during the patient’s ICU admission (Grade 2A)
Intra-abdominal pressure measurement is essential in critically ill patients at risk for IAH/ACS (Grade 1B)
Physiologic optimization is one of the determinants of early abdominal closure (Grade 2A)
Inotropes and vasopressors administration should be tailored according to patient condition and performed
surgical interventions (Grade 1A)
Fluid balance should be carefully scrutinized (Grade 2A)
High attention to body temperature should be given, avoiding hypothermia (Grade 2A)
In presence of coagulopathy or high risk of bleeding the negative pressure should be down regulated
balancing the therapeutic necessity of negative pressure and the hemorrhage risk (Grade 2B).
Technique for temporary Negative pressure wound therapy with continuous fascial traction should be suggested as the preferred
abdominal closure technique for temporary abdominal closure (Grade 2B).
Temporary abdominal closure without negative pressure (e.g. Bogota bag) can be applied in low resource
settings accepting a lower delayed fascial closure rate and higher intestinal fistula rate (Grade 2A).
No definitive recommendations can be given about temporary abdominal closure with NPWT in combination
with fluid instillation even if it seems to improve results in trauma patients (Not grades).
Re-exploration before Open abdomen re-exploration should be conducted no later than 24-48 hours after the index and any subsequent
definitive closure operation, with the duration from the previous operation shortening with increasing degrees of patient
non-improvement and hemodynamic instability (Grade 1C).
The abdomen should be maintained open if requirements for on-going resuscitation and/or the source of
contamination persists, if a deferred intestinal anastomosis is needed, if there is the necessity for a planned
second look for ischemic intestine and lastly if there are concerns about abdominal compartment syndrome
development (Grade 2B).
Nutritional support Open abdomen patients are in a hyper-metabolic condition; immediate and adequate nutritional support is
mandatory (Grade 1C).
Open abdomen techniques result in a significant nitrogen loss that must be replaced with a balanced nutrition
regimen (Grade 1C).
Table 2 Summary of statements (Continued)

Statements
Early enteral nutrition should be started as soon as possible in presence of viable and functional
gastrointestinal tract (Grade 1C).
Enteral nutrition should be delayed in patients with an intestinal tract in discontinuity (temporarily stapled
stumps), or in situations of a high output fistula with no possibility to obtain feeding access distal to the fistula
or with signs of intestinal obstruction (Grade 2C)
Oral feeding is not contraindicated and should be used where possible (Grade 2C).
Patient mobilization To date, no recommendations can be made about early mobilization of patients with open abdomen (Not graded).
Definitive closure
Trauma and non-trauma patients Fascia and/or abdomen should be definitively closed as soon as possible (Grade 1C).
Open abdomen definitive Early fascial and/or abdominal definitive closure should be the strategy for management of the open abdomen
closure once any requirements for on-going resuscitation have ceased, the source control has been definitively
reached, no concern regarding intestinal viability persist, no further surgical re-exploration is needed and there
are no concerns for abdominal compartment syndrome (Grade 1B).
➢ Non-mesh-mediated Primary fascia closure is the ideal solution to restore the abdominal closure (2A).
techniques
Component separation is an effective technique; however it should not be used for fascial temporary closure. It
should be considered only for definitive closure (Grade 2C).
Planned ventral hernia (skin graft or skin closure only) remains an option for the complicated open abdomen
(i.e. in the presence of entero-atmospheric fistula or in cases with a protracted open abdomen due to
underlying diseases) or in those settings where no other alternatives are viable (Grade 2C)
➢ Mesh-mediated The use of synthetic mesh (polypropylene, polytetrafluoruroethylene (PTFE) and polyester products) as a fascial
techniques bridge should not be recommended in definitive closure interventions after open abdomen and should be
placed only in patients without other alternatives (Grade 1B).
Biologic meshes are reliable for definitive abdominal wall reconstruction in the presence of a large wall defect,
bacterial contamination, comorbidities and difficult wound healing (Grade 2B).
Non–cross-linked biologic meshes seem to be preferred in sublay position when the linea alba can be
reconstructed. (Grade 2B).
Cross-linked biologic meshes in fascial-bridge position (no linea alba closure) maybe associated with less
ventral hernia recurrence (Grade 2B).
NPWT can be used in combination with biologic mesh to facilitate granulation and skin closure (Grade 2B).
Complications management
Trauma and non-trauma patients Preemptive measures to prevent entero-atmospheric fistula and frozen abdomen are imperative (i.e. early
abdominal wall closure, bowel coverage with plastic sheets, omentum or skin, no direct application of synthetic
prosthesis over bowel loops, no direct application of NPWT on the viscera and deep burying of intestinal
anastomoses under bowel loops) (Grade 1C).
Entero-atmospheric fistula management should be tailored according to patient conditions, fistula output and
position and anatomical features (Grade 1C)
In the presence of entero-atmospheric fistula the caloric intake and protein demands are increased; the
nitrogen balance should be evaluated and corrected and protein supplemented (Grade 1C).
Nutrition should be reviewed and optimized upon recognition of entero-atmospheric fistula (Grade 1C)
Entero-atmospheric fistula effluent isolation is essential for proper wound healing. Separating the wound into
different compartments to facilitate the collection of fistula output is of paramount importance (Grade 2A).
In the presence of entero-atmospheric fistula in open abdomen, negative pressure wound therapy makes
effluent isolation feasible and wound healing achievable (Grade 2A).
Definitive management of entero-atmospheric fistula should be delayed to after the patient has recovered
and the wound completely healed (Grade 1C).
In fact, the post-traumatic physiological derangements a higher need for OA, are acidosis with pH ≤ 7.2, lactate
and the consequent DCM expose patients at risk for levels ≥ 5 mmol/L, base deficit (BD) ≥ − 6 in patients
increased intra-abdominal pressure. Risk factors associ- older than 55 years or ≥ − 15 in patients younger than
ated with ACS requiring an OA after trauma, indicating 55 years, core temperature ≤ 34 °C, systolic pressure ≤
70 mmHg, estimated blood loss ≥ 4 L during the oper- complete fascia closure should not be attempted because
ation and/or transfusion requirement ≥ 10 U of packed of the high risk of IAH/ACS [22]. In all these situations,
red blood cells in the pre- or pre- and intraoperative the abdomen may be left open. However, there is no
settings, and severe coagulation derangements (INR/PT definitive data regarding the use of the OA in the face of
> 1.5 times normal, with or without a concomitant PTT severe peritonitis and therefore, caution should be exercised
> 1.5 times normal) [10, 13–17]. when using OA in these circumstances.
Other recognized risk factors for IAH should be kept into
consideration: obesity, pancreatitis, hepatic failure/cirrhosis, Vascular emergencies
positive end-expiratory pressure > 10 cm H20, respiratory
failure, acute respiratory distress syndrome [18]. The open abdomen should be considered following
All non-surgical treatment should be implemented to management of hemorrhagic vascular catastrophes such
prevent or reduce IAH before proceeding to surgical as ruptured abdominal aortic aneurysm (Grade 1C)
decompression (i.e., nasogastric and colonic decompres-
sion, prokinetic agents, adequate patient positioning and The open abdomen should be considered following
avoidance of constrictive dressings, eventual escharotomy surgical management of acute mesenteric ischemic
and percutaneous decompression, adequate mechanical insults (Grade 2C).
ventilation, analgesia, sedation and neuromuscular block-
ade, balanced fluid resuscitation, eventual diuretic therapy Up to 20% of patients experiencing a ruptured AAA
and continuous veno-venous hemofiltration/ultrafiltration, repair develop ACS. Mortality is high (30–50%) and is
and vasoactive medications). almost doubled in presence of ACS [23, 24]. OA reduces
Moreover, failure to definitively control the source of the ACS incidence [25]. No definitive indications to
infection at the index operation or the necessity to check OA exist; the relative indications to OA are massive
bowel perfusion during DCM or abdominal wall tissue loss resuscitation, deranged physiology, fascial tension at
represents indications to OA management in traumatic closure, use of balloon occlusion of the aorta, and
abdominal injuries [3, 11]. blood loss > 5 L [25–27].
Advanced age is not a contraindication to DCM [20].
Non-trauma patients ACS can occur even after endovascular repair (EVAR),
and the major risk factor appears to be massive resuscita-
Decompressive laparotomy is indicated in abdominal tion [23]. Risk of graft infection due to OA management
compartment syndrome if medical treatment has failed has been demonstrated to be low [28].
after repeated and reliable IAP measurements (Grade 2B) The use of OA after perfusion restoration in a patient with
acute mesenteric ischemia as in occlusive proximal or distal
superior mesenteric artery emboli, watershed necrosis after
Peritonitis AAA repairs (open or endovascular), and non-occlusive
mesenteric ischemia (e.g., post-arrest or resuscitation from
The open abdomen is an option for emergency surgery shock/arrest) should be considered in case of deranged
patients with severe peritonitis and severe sepsis/septic physiology and bowel edema and necessity to perform a
shock under the following circumstances: abbreviated second look or delayed anastomosis [29–31].
laparotomy due to severe physiological derangement, Mesenteric venous thrombosis requiring laparotomy does
the need for a deferred intestinal anastomosis, a planned not routinely mandate OA as often as mesenteric ischemia
second look for intestinal ischemia, persistent source of [32]; however, the risk of IAH/ACS imposes attention to IAP.
peritonitis (failure of source control), or extensive visceral
oedema with the concern for development of abdominal
Pancreatitis
compartment syndrome (Grade 2C).
In patients with severe acute pancreatitis unresponsive to
Some patients suffering from severe peritonitis may
step-up conservative management surgical decompression
experience a disease progression to septic shock with no
and open abdomen open are effective in treating
room for definitive surgical procedures [3, 19]. In these
abdominal compartment syndrome (Grade 2C)
cases, surgical operation should be abbreviated even in
advanced age [20]. In hypotensive patients requiring
high-dose vasopressors or inotropes infusion intestinal Leaving the abdomen open after surgical necrosectomy
continuity restoration may be deferred [21]. In incom- for infected pancreatic necrosis is not recommended
plete source control or in the presence of visceral edema except in those situations with high risk factors to
and/or decreased abdominal wall compliance primary develop abdominal compartment syndrome (Grade 1C)
MOF is the factor mainly associated with mortality in physiologically deranged patients. It passes through some
acute pancreatitis (AP) especially when infected necrosis cornerstone actions as volume resuscitation, reversal of
[33–37] is present. As in many other conditions, secondary coagulopathy, correction of acidosis, and all the other
IAH/ACS may aggravate MOF in a vicious circle [38]. IAH/ pertinent resuscitative measures aiming to restore the nor-
ACS should be prevented and treated as far as it is possible mal physiology. The fluid status, nutrition, and respiratory
with non-surgical measures. Surgical decompression is the mechanics should also be kept into consideration in
last but effective tool; it should not be delayed in case of managing OA. In fact the possibility of recurrent ACS
ACS [4, 39]. Pancreatic necrosis may become infected after with its related high mortality is to be posed into
the first week [40]. The presence of organ failure, early consideration [42–44].
bacteremia, and the extent of pancreatic necrosis are fac- Abdominal pressure should be measured in all patients
tors associated with infection [40]. Surgical necrosectomy at risk of developing IAH/ACS; in fact, it has been
should be considered when more conservative manage- demonstrated that clinical examination is inaccurate in
ment as percutaneous drainage fails [41]. In case of necro- diagnosing IAH/ACS [45]. As a general principle, it
sectomy, OA may be considered, but it is not mandatory. should be measured every 12 h and every 4–6 h once
It should be considered only if risks for IAH/ACS exist. ACS/IAH has been detected or if organ failure happens.
Physiology optimization is necessary to allow early
Management abdominal closure. In fact, prolonged OA may delay
Trauma and non-trauma patients extubation, increase the risk for EAF and frozen abdomen,
and increase complications [46].
ICU management Multidisciplinary collaboration with all teams managing
the patient is required for optimal care of OA patients.
The role of Damage Control Resuscitation in OA The real extent of heat loss in OA and a temporary
management is fundamental and may influence abdominal dressing cannot be quantified. It is well known
outcome (Grade 2A) that patient physiology is impaired by hypothermia and its
related hypo-perfusion effects such as heart function
depression, reduced oxygen delivery, coagulation cascade
A multidisciplinary approach is encouraged, especially alteration, and acidosis.
during the patient’s ICU admission (Grade 2A) In trauma patients, the “lethal triad” should be rapidly
interrupted [47–53].
It is well known that mortality increases in trauma
Intra-abdominal pressure measurement is essential in
patients with significant core-body temperature drop [54].
critically ill patients at risk for IAH/ACS (Grade 1B)
Commercial NPWT systems significantly reduce heat
loss but the non-commercial ones still maintain a reduced
Physiologic optimization is one of the determinants of heat isolation capacity. For this reason, the heat loss control
early abdominal closure (Grade 2A) is of paramount importance especially in those settings
where non-commercial systems are utilized.
During ICU stay, it is important to ensure analgesia
Inotropes and vasopressors administration should be
over hypnosis and consider multimodal analgesia to reduce
tailored to patient’s condition and performed surgical
opioid infusion, trying to keep the patient “awake” but well
interventions (Grade 1A)
adapted to mechanical ventilation. Moreover, protective
mechanical ventilation strategies should be adopted.
Fluid balance should be carefully scrutinized (Grade 2A) Fluid balance is important as well in OA management
and should be carefully scrutinized to avoid over- or
under- resuscitation. Careful monitoring and maintenance
High attention to body temperature should be given,
of adequate urinary output could help in evaluating ad-
avoiding hypothermia (Grade 2A)
equacy of resuscitation effects. Continuous monitoring
of cardiac output (CO), targeting at low/normal values,
In presence of coagulopathy or high risk of bleeding the is essential to avoid fluid overload and vasopressor
negative pressure should be down regulated balancing abuse. If increasing vasopressors induce low CO, and
the therapeutic necessity of negative pressure and the fluid responsiveness is transient, consider to target
hemorrhage risk (Grade 2B). treatments (included inotropes) to the best compromise
between MAP, CO, and fluid amount. High-rate mainten-
The initial management is fundamental. DCR is part ance fluid infusions should be avoided. As a counterpart,
of DCM utilized in treating severely injured and severely whenever possible, frequent, small-volume fluid boluses
should be preferred. Hypertonic crystalloid and colloid- closure and mortality rate. The results favored the non-
based resuscitation seem to decrease the risk of iatrogenic, negative pressure systems in trauma and negative pressure
induce resuscitation, and increase IAP [55]. Daily patient temporary closure in severe peritonitis patients [46]. Also,
weights may help in evaluating fluid retention. recent contradictory data from a single-center RCT showed
Inotrope infusion should be balanced keeping in mind that NPWT and fluid instillation seemed to improve out-
the patients’ condition, the performed surgical procedures, comes in trauma patients in terms of early and primary
and the necessity to prevent further complications due to closure [64].
their overuse [56, 57]. Another important issue in OA management is the
Volumetric-based monitoring technologies can be very necessity to balance the antimicrobial therapy in relation
useful in hemodynamic evaluation during DCR phases in to positive cultures of intra-abdominal fluids. Two options
critically ill patients. In fact, the elevated intra-abdominal are generally followed without any strong literature
and intra-thoracic pressure can impair the real value of the evidence: treating all the cultured organisms (with high
measurements obtained with traditional pressure-based proportions of staphylococci, candida, and MDR Gram-
parameters such as pulmonary artery occlusion pressure negative bacilli including Pseudomonas) or a “wait and
and central venous pressure [58–60]. The alteration of see” strategy. WSES suggests to follow guidelines for
these parameters can potentially lead to wrong decisions intra-abdominal infections [65].
as regards the correct fluid status and as a consequence
the necessary amount of fluid to be administered. This
balance is essential also to optimize the surgical success Re-exploration before definitive closure
of primary fascial closure [12, 61, 62].
Open abdomen re-exploration should be conducted no
later than 24-48 hours after the index and any subsequent
Technique for temporary abdominal closure operation, with the duration from the previous operation
shortening with increasing degrees of patient non--
Negative pressure wound therapy with continuous improvement and hemodynamic instability (Grade
fascial traction should be suggested as the preferred 1C).
technique for temporary abdominal closure (Grade 2B).
The abdomen should be maintained open if
Temporary abdominal closure without negative pressure requirements for on-going resuscitation and/or the
(e.g. Bogota bag) can be applied in low resource settings source of contamination persists, if a deferred intestinal
accepting a lower delayed fascial closure rate and higher anastomosis is needed, if there is the necessity for a
intestinal fistula rate (Grade 2A). planned second look for ischemic intestine and lastly if
there are concerns about abdominal compartment
No definitive recommendations can be given about syndrome development (Grade 2B).
temporary abdominal closure with NPWT in
combination with fluid instillation even if it seems to Indications to re-explore an OA may vary between
improve results in trauma patients (Not graded). trauma and non-trauma patients. In general, the patient’s
non-improvement possibly is due to an intra-abdominal
Several strategies to maintain the OA have been de- reason. No definitive data regarding the timing of re-
scribed. They result in different delayed fascial closure rate operation in OA patients exist [6, 66]. It is generally
and EAF risk. In general, negative pressure associated to a recommended that OA patients should be re-explored
dynamic component (mesh-mediated fascial traction or 24–72 h after the initial or any subsequent surgical
dynamic sutures) allows to reach the best results in terms intervention [2, 67, 68]. Some data regarding trauma
of delayed fascial closure, but dynamic sutures result more patients showed that the time of re-exploration reduces
often in fistula [3]. Negative pressure without a dynamic the primary fascial closure rate of 1.1% for each hour
component (Barker’s VAC or commercial products) after the first 24 h after the index operation [69]. More-
results in a moderate delayed fascial closure rate and a over, increased complication rate was observed in patients
fistula rate similar to mesh closure without negative having the first re-operation after 48 h [3, 69].
pressure [3]. In non-trauma patients, the indication to re-explore
Recent data from the International Register of Open the abdominal cavity are less definite and usually are due
Abdomen (IROA study) showed that different techniques to the necessity to continue DCM, to the impossibility
of OA resulted in different results according to the treated to definitively control the source of infection or to the
disease [63] (trauma and severe peritonitis) and if treated necessity to re-asses the bowel vascularization or lastly, to
with or without negative pressure in terms of abdominal concerns regarding the possibility of ACS [2, 3, 20, 70].
Even though there is some evidence that OA may be Patient mobilization

justified in severely injured or physiologically deranged
patients with the aim to manipulate the systemic immune No recommendations can be made about early
response and ameliorate the bio mediator burden, no mobilization of patients with open abdomen (Not
definitive statement can be made [3, 71–75]. graded).
Nutritional support No definite evidence exists regarding the optimal

timing for mobilization of patients with OA [84]. Pro-
Open abdomen patients are in a hyper-metabolic longed bed rest is associated with a significant increase
condition; immediate and adequate nutritional support in morbidity. Mobilization occurring within the first
is mandatory (Grade 1C). 2-5 days of ICU admission is defined “early” [85] and it is
associated with positive effects on outcomes [86–90].
OA patients with NPWT may be “early” mobilized
Open abdomen techniques result in a significant
by active or passive transfer thanks to the provisional
nitrogen loss that must be replaced with a balanced
abdominal wall function supplied by NPWT systems [3].
nutrition regimen (Grade 1C).
Early enteral nutrition should be started as soon as Definitive closure

possible in the presence of viable and functional Open abdomen definitive closure
gastrointestinal tract (Grade 1C).
Fascia and/or abdomen should be definitively closed

Enteral nutrition should be delayed in patients with as soon as possible (Grade 1C).
an intestinal tract in discontinuity (temporarily closed
loops ), or in situations of a high output fistula with no
possibility to obtain feeding access distal to the fistula Early fascial and/or abdominal definitive closure
or with signs of intestinal obstruction (Grade 2C) should be the strategy for management of the open
abdomen once any requirements for on-going
Oral feeding is not contraindicated and should be used resuscitation have ceased, the source control has
where possible (Grade 2C). been definitively reached, no concern regarding
intestinal viability persist, no further surgical re-ex-
Malnutrition is a risk factor for poor outcomes [76]. ploration is needed and there are no concerns for
Critically ill patients with OA are in a hyper-catabolic abdominal compartment syndrome (Grade 1B).
state with an estimated nitrogen loss of almost 2 g/L of
abdominal fluid output. Abdominal fluid evacuation is The priority in order to reduce mortality, complications,
to be measured in order to adjust nutritional integra- and length of stay linked to the OA should be the early
tions [77]. In case of EAF, nitrogen loss greatly increases. definitive abdominal closure [10, 91, 92]. Major factors
Parenteral nutrition should be started as soon as possible. influencing early definitive closure are postoperative ICU
Once the resuscitation is almost complete and the GI tract management and the TAC technique [93]. Early fascial
is viable, enteral nutrition (EN) should be started. Relative closure is commonly defined as occurring within 4–7 days
contraindication to EN is a viable bowel shorter than from the index operation [21]. In contrast to trauma
75 cm [78]. patients, those affected by abdominal sepsis usually
Polymeric formula supplying a daily intake of 20- to experience a lower rate of early fascial closure [94] even
30-kcal/kg non-protein calories with 1.5- to 2.5-g/kg though continuous fascial traction seems to increase
proteins is usually sufficient to maintain a positive this rate [95]. Fascial closure should be attempted as
nitrogen balance. soon as the source of infection is controlled [96].
EN starting within the first 24–48 h improves wound
healing and fascial closure rate, decreases catabolism,
reduces pneumonia and fistula rate, preserves GI tract Solutions to definitively close an open abdomen
integrity, and finally reduces complications, length of In case of prolonged OA, fascia retraction and large ab-
hospital stay, and costs [79–81]. Compared to prolonged dominal wall defects requiring complex abdominal wall
total parenteral nutrition, early EN decreases septic reconstruction may occur. In contaminated fields, the
complications especially in abdominal trauma and trau- complication risk in abdominal wall definitive closure is
matic brain injuries [3, 79, 82, 83]. increased [92, 97–99].
Techniques used to definitively close the abdomen are defect, bacterial contamination, comorbidities and
principally divided into non-mesh and mesh mediated. difficult wound healing (Grade 2B).
Non-mesh-mediated closure techniques Non–cross-linked biologic meshes seem to be preferred

in sublay position when the linea alba can be
Primary fascia closure is the ideal solution to restore reconstructed. (Grade 2B).
the abdominal closure (2A).
Cross-linked biologic meshes in fascial-bridge position
Component separation is an effective technique; (no linea alba closure) maybe associated with less ventral
however it should not be used for fascial temporary hernia recurrence (Grade 2B).
closure. It should be considered only for definitive
closure (Grade 2C).
NPWT can be used in combination with biologic mesh
to facilitate granulation and skin closure (Grade 2B).
Planned ventral hernia (skin graft or skin closure only)
remains an option for the complicated open abdomen Several data exist regarding the abdominal wall
(i.e. in the presence of entero-atmospheric fistula or in closure after OA [104, 105]. Non-absorbable synthetic
cases with a protracted open abdomen due to under- materials (i.e., polypropylene mesh) in a bridging pos-
lying diseases) or in those settings where no other alter- ition (i.e., no linea alba closure), where no native tissue
natives are viable (Grade 2C) protect viscera, may induce several local side effects
(adhesions, erosions, and fistula formation) [106–111].
Abdominal component separation should be consid- Synthetic meshes in contaminated fields are not rec-
ered an elective procedure for ventral hernia repair ommended by guidelines in emergency abdominal wall
[100]. In fact, it should not be used during the OA man- reconstruction [112].
agement but reserved to the definitive closure interven- Biological prostheses (BP) were designed to perform as
tions. At a delayed time point, very good results permanent surgical prosthesis in abdominal wall repair,
reaching up to 75% of fascial closure rate have been re- minimizing mesh-related complications. Non-cross-linked
ported [101]. The separation of components can be biologic mesh is easily integrated, with reduced fibrotic re-
approached anteriorly or posteriorly [102, 103]. action and lesser infection and removal rate [113].
Planned ventral hernia represents a valid alternative to BP can be used as a bridge for large abdominal wall de-
cover abdominal viscera and to prevent EAF. In fact, in fects [114–127]; however, the long-term outcome of a
cases of persistent contamination, several comorbidities bridging non-cross-linked BP is laxity of the abdominal wall
or in severely ill patients, with or without sufficient skin and a high rate of recurrent ventral hernia [113]. As a con-
to cover the abdominal wall defect, delaying the eventual sequence, non-cross-linked BP should be used in a sublay
synthetic prosthetic reconstruction may be a safer op- position (i.e., with linea alba closure) and cross-linked ones
tion. The decision either to close the skin or to perform should be preferred when the fascial bridge is needed [128–
vascularized flaps, pedicled flaps in small-/mid-sized de- 130]. BP could also tolerate adjunctive NPWT to facilitate
fects, or free flaps such as tensor fasciae latae for exten- wound healing, granulation, and skin closure [131–133].
sive thoraco-abdominal defects is usually taken,
considering the wound conditions, the dimension of the
Complication management
skin defect, and the center facilities [13].
Mesh-mediated closure techniques Preemptive measures to prevent entero-atmospheric

fistula and frozen abdomen are imperative (i.e. early
The use of synthetic mesh (polypropylene, abdominal wall closure, bowel coverage with plastic
polytetrafluoruroethylene (PTFE) and polyester sheets, omentum or skin, no direct application of
products) as a fascial bridge should not be synthetic prosthesis over bowel loops, no direct
recommended in definitive closure interventions after application of NPWT on the viscera and deep
open abdomen and should be placed only in patients burying of intestinal anastomoses under bowel
without other alternatives (Grade 1B). loops) (Grade 1C).
Entero-atmospheric fistula management should be

Biologic meshes are reliable for definitive abdominal tailored according to patient condition, fistula output
wall reconstruction in the presence of a large wall and position and anatomical features (Grade 1C).
In the presence of entero-atmospheric fistula the cal- early abdominal wall closure, bowel coverage with
oric intake and protein demands are increased; the ni- plastic sheets, omentum or skin, no direct application
trogen balance should be evaluated and corrected and of synthetic prosthesis on bowel, no direct application
protein supplemented (Grade 1C). of NPWT on the viscera, and intestinal anastomosis
deep buring under bowel loops [73, 141, 142]. EAF
Nutrition should be reviewed and optimized upon can be classified based on the output: low (< 200 mL/
recognition of entero-atmospheric fistula (Grade 1C). day), moderate (200–500 mL/day), and high (>
500 mL/day) [143]; usually, the greater the output, the
higher the difficulty in managing the EAF [144, 145]. In
Entero-atmospheric fistula effluent isolation is essential
EAF management, the definition of characteristics and
for proper wound healing. Separating the wound into
anatomical features are extremely important in plan-
different compartments to facilitate the collection of
ning the best treatment [146]. The intra-abdominal
fistula output is of paramount importance (Grade 2A).
situation can be classified according to the WSACS
classification (Fig. 2) [147]. Nutrition plays a pivotal
In the presence of entero-atmospheric fistula in open role in EAF management. While early EN improves
abdomen, negative pressure wound therapy makes outcomes [81, 148–151], it may increase EAF output
effluent isolation feasible and wound healing achiev- even if it seems not to impair final outcomes [152,
able (Grade 2A). 153]. Spontaneous closure of an EAF is quite impos-
sible; for this reason, the treatment should try to isolate
Definitive management of entero-atmospheric fistula the fistula effluent to allow granulation tissue formation
should be delayed to after the patient has recovered around [3]. Many different effective techniques have been
and the wound completely healed (Grade 1C). described with no definitive results [138, 144, 145, 154–
157]. NPWT in all its variants is effective and the most
Risk factors for frozen abdomen and EAF in OA accepted technique [3]. It often allows EAF isolation,
are delayed abdominal closure, non-protection of adequate wound management, re-epithelization, and
bowel loops during OA, presence of bowel injury and eventual subsequent skin graft with the final conversion
repairs or anastomosis, colon resection during DCS, of the EAF into a sort of enterostomy. EAF definitive
the large fluid resuscitation volume (> 5 L/24 h), the treatment (i.e., fistula closure and abdominal wall re-
presence of intra-abdominal sepsis/abscess, and the construction) should be postponed at least of 6 months
use of polypropylene mesh directly over the bowel and only after the patient and the wound healed com-
[66, 134–139]. All risk factors often linked as a “vi- pletely [3].
cious cycle” may contribute to the development of
frozen abdomen and EAF. Complications increase Conclusions
mortality, length of stays, and costs [140]. Some pre- Open abdomen in trauma and non-trauma patients is
emptive measures to prevent this complication are dramatically effective in facing the deranged
Fig. 2 Open Abdomen classification according to Björck et al. [147]

physiology of severe injuries or critical illness when Health, Denver, CO, USA. 7Department of Surgery, UC San Diego Health
no other perceived options exist. Its use remains very System, San Diego, USA. 8Faculdade de Ciências Médicas (FCM)–Unicamp
Campinas, Campinas, SP, Brazil. 9Department of Surgery, College of Medicine
controversial and is a matter of great debate, as it is and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
a non-anatomic situation with potential severe side 10
Department of Surgery, Macerata Hospital, Macerata, Italy. 11Department of
effects and increased resource utilization. Moreover, Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General
Hospital, Boston, MA, USA. 12Second Department of Surgery, Meilahti
the lack of definitive data demands carefully tailoring Hospital, Helsinki, Finland. 13Trauma and Acute Care Surgery and Surgical
its use to each single patient, taking care to not over- Critical Care Trauma, Department of Surgery, University of California, Davis,
use it. Abdominal closure attempt should be done as USA. 14General and Emergency Surgery, McGill University Health Centre,
Montréal, QC, Canada. 15Department of Surgery, Harborview Medical Centre,
soon as the patient can physiologically tolerate it. All Seattle, USA. 16General Surgery Department, Hadassah Medical Centre,
possible precautions should be implemented to Jerusalem, Israel. 17First Clinic of General Surgery, University Hospital/UMBAL/
minimize complications. Results improve proportionate St George Plovdiv, Plovdiv, Bulgaria. 18General Surgery, Mozir Hospital, Mozir
City, Belarus. 19ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen,
to the clinicians’ team’s experience with the intricacies Antwerpen, Belgium. 20Department of Surgery, Trauma and Surgical Services,
of open abdomen management. University of Pittsburgh School of Medicine, Pittsburgh, USA. 21Department
of Surgery, Tbilisi State Medical University, Kipshidze Central University
Abbreviations Hospital, Tbilisi, Georgia. 22General Surgery Department, Letterkenny Hospital,
AAST: American Association for the Surgery of Trauma; ACS: Abdominal Letterkenny, Ireland. 23Addenbrooke’s Hospital, Cambridge, UK. 24Klinik für
compartment syndrome; AP: Acute pancreatitis; CO: Cardiac output; Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum
DCM: Damage control management; DCR: Damage control resuscitation; Goethe-Universität Frankfurt, Frankfurt, Germany. 25Department of Clinical
DCS: Damage control surgery; EAF: Entero-atmospheric fistula; EN: Enteral Medicine, University of Bergen, Bergen, Norway. 26Department of
nutrition; EVAR: Endovascular repair; GRADE: Grading of Recommendations Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
27
Assessment, Development and Evaluation; IAH: Intra-abdominal Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI, USA.
28
hypertension; IAP: Intra-abdominal pressure; INR: International normalized General and Trauma Surgery Department, London Health Sciences Centre,
ratio; MAP: Mean arterial pressure; MOF: Multiple organ failure; Victoria Hospital, London, ON, Canada. 29Département
NPWT: Negative pressure wound therapy; OA: Open abdomen procedure; d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance
PTFE: Polytetrafluoruroethylene; rAAA: Ruptured abdominal aortic aneurysm; Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France. 30ICU
RCT: Randomized controlled trial; TAC: Temporal abdominal closure; Department, Sant’Orsola-Malpighi University Hospital, Bologna, Italy. 31ICU
TEG: Thromboelastography; TPN: Parenteral nutrition; WSACS: World Society Department, Papa Giovanni XXIII Hospital, Bergamo, Italy. 32Surgery
Abdominal Compartment Syndrome; WSES: World Society of Emergency Surgery Department, University of Maryland School of Medicine, Baltimore, MD, USA.
33
Emergency and Trauma Surgery Department, Niguarda Hospital, Milano,
Acknowledgements Italy. 34General Surgery Department, Assuta Medical Centers, Tel Aviv, Israel.
Special thanks to Ms. Franca Boschini (Bibliographer, Medical Library, Papa 35
General Surgery, “General Calixto García”, Habana Medicine University,
Giovanni XXIII Hospital, Bergamo, Italy) for the precious bibliographical work. Havana, Cuba. 36General Surgery, Medical Faculty “General Calixto Garcia”,
Habana Medicine University, Havana, Cuba. 37Division of Trauma, Department
Funding of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, Republic
None of China. 38Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU
Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France. 39General
Availability of data and materials and Emergency Surgery Department, Empoli Hospital, Empoli, Italy.
40
Not applicable Department of Cardiothoracic and Vascular Surgery, Örebro University
Hospital and Örebro University, Orebro, Sweden. 41General Surgery,
Authors’ contributions Perpignan Hospital, Perpignan, France. 42Pediatric Trauma Service,
FCo, DR, LA, RI, EG, YK, EEM, RC, AWK, BMP, GM, MCe, FMA-Z, MSa, GV, GPF, Massachusetts General Hospital, Boston, MA, USA. 43General and Emergency
AL, MTol, JG, TR, RM, MB, BS, VK, MM, VA, AP, ZD, MSu, SDS, IM, KS, WB, PFe, Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia. 44Unit of
NP, PMo, RMM, FS, TMV, TS, OC, SC, JLK, ML, JAMH, HFL, MCh, CA, CB, TH, Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital,
BDS, PMa, VR, NDA, KK, ZJB, PFu, MTom, RL, NN, DW, LH, KI, AH, YKC, CAO, Créteil, France. 45Department of Primary Care and Emergency Medicine,
SR, CAG, MDM, IW, ACM, KB, LN, and FCa contributed to the manuscript con- Kyoto University Graduate School of Medicine, Kyoto, Japan. 46Department of
ception and draft, critically revised the manuscript, contributed with the im- Traumatology, John Hunter Hospital and University of Newcastle, Newcastle,
portant scientific knowledge, and gave final approval of the manuscript. NSW, Australia. 47General Surgery Department, Westchester Medical Center,
Westchester, NY, USA. 48Department of Surgery, University of KwaZulu-Natal,
Ethics approval and consent to participate Durban, South Africa. 49Department of General Surgery, Royal Perth Hospital,
Not applicable The University of Western Australia & The University of Newcastle, Perth,
Australia. 50Trauma Unit, Helsinki University Hospital, Helsinki, Finland.
51
Consent for publication Division of Trauma and Critical Care, LAC+USC Medical Center, University
Not applicable of Southern California, California, Los Angeles, USA. 52General and Thoracic
Surgery, Giessen Hospital, Giessen, Germany. 53Acute Care Surgery and
Competing interests Traumatology, Taipei Medical University Hospital, Taipei City, Taiwan,
The authors declare that they have no competing interests. Republic of China. 54Trauma and Acute Care Surgery, Fundacion Valle del Lili,
Cali, Colombia. 55Trauma and Acute Care Service, St Michael’s Hospital,
Toronto, ON, Canada. 56Hospital Universitário Terezinha de Jesus, Faculdade
Publisher’s Note de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora,
Springer Nature remains neutral with regard to jurisdictional claims in Brazil. 57Trauma, Acute Care Surgery, Medical College of Wisconsin/Froedtert
published maps and institutional affiliations. Trauma Center, Milwaukee, WI, USA. 58Department of Surgery, Sheri-Kashmir
Institute of Medical Sciences, Srinagar, India. 59Department of Surgery and
Author details Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon.
1
General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni 60
Milpark Hospital Academic Trauma Center, University of the Witwatersrand,
Ghirotti, 286, 47521 Cesena, Italy. 2Department of Surgery, Foothills Medical Johannesburg, South Africa. 61Acute Care Surgery, Department of Surgery,
Centre, Calgary, Canada. 3Virginia Commonwealth University, Richmond, VA, University of Michigan Health System, Ann Arbor, MI, USA. 62Emergency and
USA. 4ICU Department, Bufalini Hospital, Cesena, Italy. 5Division of General Trauma Surgery, Parma Maggiore Hospital, Parma, Italy.
Surgery, Rambam Health Care Campus, Haifa, Israel. 6Trauma Surgery, Denver
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Coccolini et al.

World Journal of Emergency Surgery (2018) 13:7

REVIEW Open Access

The open abdomen in trauma and

Background using OA. It should not be performed liberally. Measures

Table 1 GRADE system to evaluate the level of evidence and recommendation

Persistent hypotension, acidosis (pH <7.2),

Table 2 Summary of statements

Table 2 Summary of statements (Continued)

Even though there is some evidence that OA may be Patient mobilization

Nutritional support No definite evidence exists regarding the optimal

Early enteral nutrition should be started as soon as Definitive closure

Fascia and/or abdomen should be definitively closed

Non-mesh-mediated closure techniques Non–cross-linked biologic meshes seem to be preferred

Mesh-mediated closure techniques Preemptive measures to prevent entero-atmospheric

Entero-atmospheric fistula management should be

Fig. 2 Open Abdomen classification according to Björck et al. [147]

to rationalize the approach to a surgical nightmare and proposal of a

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