Abdominal wall reconstruction following open abdomen management

Authors

Abstract

Aim Open abdomen (OA) management remains a demanding aspect of acute care and reconstructive surgery. The timing and method of definitive abdominal wall closure critically influence morbidity, enteroatmospheric fistula formation, and long-term hernia development. In this study, we analyzed three-year outcomes of 34 OA patients and compared the effectiveness of early primary fascial closure (PFC), anterior component separation (Ant. CS), transversus abdominis release (TAR), and skin-only closure within evidence-based timing strategies.
Materials and Methods A retrospective single-center cohort (2022–2024) of adult OA patients managed with vacuum-assisted therapy was evaluated. Closure techniques were categorized by timing: early (≤ 7 days), intermediate (7–21 days), and late (> 21 days). Outcomes included closure success, complications, need for mesh, and hospitalization.
Results Early PFC was achieved in 11 patients (32%), showing the lowest complication rate and no fistula formation. Ant. CS was used in 8 patients (3 early, 3 intermediate, 2 late). TAR was performed in 4 late-phase cases and demonstrated the highest morbidity and mesh requirement. Eleven patients underwent skin-only closure; 5 declined subsequent reconstruction. Closure success strongly correlated with early timing.
Discussion Early PFC remains the optimal strategy in OA management. Ant. CS provides a safe intermediate option, while TAR is reserved for complex late defects but is associated with increased morbidity. Skin-only closure is lifesaving but results in a predictable ventral hernia burden. A structured, algorithm- based approach aligned with contemporary guidelines optimizes outcomes.

Keywords

Introduction

The open abdomen (OA) represents a life-saving surgical strategy used in conditions such as abdominal compartment syndrome, severe sepsis, trauma, and ischemia when definitive closure poses risks of physiologic deterioration. Despite its necessity, OA is associated with considerable morbidity due to fluid loss, visceral exposure, systemic inflammation, fascial retraction, and the risk of enteroatmospheric fistula formation [1, 2, 3, 4]. The overarching clinical priority in OA management is early primary fascial closure (PFC), which is linked to shorter intensive care unit stays, lower infection rates, and better long- term abdominal wall integrity [5, 6, 7, 8].
However, patient instability, uncontrolled contamination, visceral edema, and sepsis commonly delay definitive closure. In such cases, surgeons may employ reconstructive strategies such as anterior component separation (Ant. CS) or posterior component separation with transversus abdominis release (TAR) to restore midline continuity [9, 10, 11, 12]. When definitive reconstruction is unsafe, skin-only closure is often performed as a temporizing or palliative measure, though it inevitably results in a planned incisional hernia [13].
Given the heterogeneity of OA patients and the varying degrees of tissue damage and contamination, closure strategy selection must be tailored to defect complexity and physiological readiness. This study provides a comprehensive three-year assessment of OA closure outcomes in 34 patients, comparing four major reconstructive strategies across defined timing categories and contextualizing findings within contemporary international literature.

Materials and Methods

A retrospective cohort study was conducted at a tertiary surgical center between January 2022 and December 2024 following institutional ethics approval. Patient inclusion criteria were: age over18 years, open abdomen following emergency laparotomy, documented closure attempt, and complete clinical data. A total of 34 patients were included. Patients with mortality before closure attempt, missing operative documentation, or prior complex abdominal wall reconstruction were excluded.
Indications for open abdomen were abdominal compartment syndrome, severe peritonitis, mesenteric ischemia, blunt or penetrating trauma, and refractory septic shock.
All patients received vacuum-assisted closure (VAC) therapy for temporary abdominal closure. Benefits include: visceral protection, enhanced medial fascial traction, edema reduction, and decreased fistula formation when barriers are used [14– 16]. Dressings were changed every 48–72 hours.
Early closure (first week) was attempted in 14 patients. In 11 of them, PFC was used, and in 3, Ant. CS was used. Intermediate Closure (7–21 days) was attempted in 3 patients with Ant.CS method.
Late Closure (> 21 days) was attempted in 17 patients. In 2 of them, Ant. CS was used in 4 of them, TAR was used, and in 11 of them, only the skin closure method was used.
Variables were analyzed according to patient demographics, timing and method of closure, postoperative surgical and infectious complications, length of stay, and mortality.
Descriptive statistics (mean, SD, percentages) were used due to sample size limitations.
Surgical Technique
In Ant. CS technique, abdominal exploration had been done, and perforating vessels were protected during the lateral abdominal dissection. After that, lateral fascial incisions to the aponeurosis of the external oblique muscle were made for the abdominal wall relaxation. [Figure 1]. Then, primary closure of the abdomen was performed by using 0-Prolene continuous closure. Onlay Prolene mesh was applied to the whole zone. In the TAR technique, after the abdominal exploration, an incision is made on the posterior rectus sheet(pRS) positioned 5 mm from the midline to enter the Rives-Stoppa plane. This incision is then extended along the entire length in both cranial and caudal directions, revealing the Rives-Stoppa plane. Neurovascular bundles are identified, and an incision is taken on the posterior lamella of the internal oblique 5 mm medial to the neurovascular bundles to expose the transversus abdominis muscle (TA). An incision was made on the TA muscle to enter the TAR plane. Small bites of short bursts of monopolar energy are used to divide the muscle fibres. Then, pRS was closed with 0-prolene continuous closure (Figure 2). After closure of the posterior sheet, self-gripping meshes are placed under RA. Drainage tubes are placed in both areas, and the anterior sheet was closed by the small-bite technique.
Ethical Approval
The study was approved by the Ethics Committee of Istanbul Göztepe Prof. Dr. Süleyman Yalçın City Hospital (Date: 2016- 03-08, No: 2016/0075).

Results

Among the 34 OA patients, early PFC was achieved in 11 (32%), demonstrating the best outcomes with minimal complications. The mean patient age was 44 years. There were 3 male and 8 female patients. There were 2 wound infections, and the average length of stay was 4 days. There was one recurrence after a one-year follow-up (Table 1). When PFC was not feasible, early Ant. CS enabled successful closure in an additional 3(9%) patients. The mean patient age was 48 years. There were 1 male and 2 female patients. There were 2 wound infections, and the average length of stay was 6 days. There was no recurrence after a one-year follow-up.
Intermediate Ant. CS was effective in 3 (9%) cases, reflecting its utility when the abdomen remained contaminated or physiologically unstable in the early period. The mean patient age was 52 years. There were 1 male and 2 female patients. There was 1 wound infection, and the average length of stay was 8 days. There was one recurrence after a one-year follow- up.
Seventeen patients required late closure, primarily due to persistent contamination or pronounced loss of abdominal domain. Among them, TAR was used in 4(12%) cases and offered the greatest medialization potential but also the highest complication rate. The mean patient age was 61 years. There were 1 male and 3 female patients. There was 1 wound infection and the average length of stay was 11 days. There was one recurrence after a one-year follow-up. Ant CS was used for late closure in an additional 2(6%) patients. The mean patient age was 42 years. There were 1 male and 1 female patient. There was 1 wound infection, and the average length of stay was 8 days. There was no recurrence after a one-year follow- up. Skin-only closure was performed in 11(32%) patients; all developed a planned incisional hernia. The mean patient age was 78 years. There were 5 male and 6 female patients. There were 8 wound infections, and the average length of stay was 20 days.
Complication rates strongly correlated with timing: Early PFC group with the lowest infection rates, no fistulas; Intermediate Ant. CS with moderate morbidity, acceptable closure rates; Late TAR with the highest wound complications, and Skin-only closure: universally resulted in hernia formation.

Discussion

Management of the open abdomen continues to pose significant clinical and technical challenges, requiring the surgeon to balance the need for rapid physiological stabilization with the goal of restoring the abdominal wall. The results of this study strongly reaffirm the principle that early PFC is the gold standard in OA management. Early closure minimizes systemic inflammation, fluid loss, and fascial retraction while reducing the risk of enteroatmospheric fistula formation [1, 5, 8]. Our cohort demonstrated that early PFC achieved the most favorable outcomes, consistent with large-scale analyses reporting significantly reduced morbidity and mortality when closure occurs within the first week [14, 15]. The ability to close the abdomen early is closely linked to effective resuscitation, optimized sepsis control, and the widespread adoption of VAC therapy protocols, which collectively contribute to a more favorable operative environment.
For patients who cannot undergo early closure with PFC due to persistent contamination, sepsis, or visceral edema, Ant. CS provides a valuable intermediate-stage reconstructive option. In our cohort, Ant. CS performed during the intermediate window resulted in satisfactory closure with acceptable morbidity, reflecting the benefits of modern modifications that preserve perforating vessels and reduce wound complications. Contemporary evidence supports these findings by showing that perforator-sparing CS techniques significantly reduce ischemic skin complications compared to traditional methods [9, 10, 11]. Ant. CS thus serves as a critical bridge between early physiologic instability and the late need for more complex reconstruction. In contrast, patients presenting in the late phase with substantial fascial retraction and loss of domain often require TAR. TAR has become a cornerstone in complex abdominal wall reconstruction due to its ability to generate large myofascial advancement and accommodate wide mesh placement in a well-vascularized retro-muscular plane [11, 12]. However, TAR is associated with higher morbidity—particularly when performed in previously contaminated or septic fields—due to increased tissue dissection, prolonged operative times, and higher risk of surgical site infections [11, 12]. Our results align with existing literature, demonstrating that late TAR carries significant wound complication risk and should be reserved for patients who are physiologically optimized and fully recovered from the early inflammatory phase.
Skin-only closure continues to serve as an essential life-saving measure for unstable patients in whom definitive closure is unsafe. Although straightforward to perform, it invariably results in a planned ventral hernia, a finding consistent with our study and prior literature [13, 14]. Notably, a substantial portion of patients declined later reconstruction, highlighting a real-world challenge related to the psychological burden, socioeconomic limitations, and perceived surgical risks associated with additional operations. This underscores the need for early counseling and shared decision-making to ensure patients understand the long-term implications of skin-only closure.
Negative pressure therapy (VAC) played a crucial role in achieving the closure rates observed in this cohort. VAC has been shown to promote fascial traction, improve wound bed conditioning, and decrease fluid accumulation, contributing to higher closure rates and reduced complications [15, 16, 17, 18, 19]. In our study, mandatory use of VAC therapy likely contributed to the relatively high proportion of patients who achieved early or intermediate closure despite initial severity.
Overall, the findings of this study support a structured, algorithm-driven approach consistent with WSES and WSACS recommendations, emphasizing early closure whenever feasible, careful assessment during VAC therapy, and selective use of Ant. CS in the intermediate phase, and judicious application of TAR in late or complex cases [1, 2, 7]. Although limited by its retrospective design and modest sample size, this cohort provides valuable insight into timing-based OA management strategies and highlights the critical importance of individualized, physiology-based decision-making. Future studies should incorporate long-term functional outcomes and multi-institutional data to refine closure algorithms further.

Limitations

Our study has some limitations. First, the sample size is relatively small, reflecting the fact that only a subset of open abdomen cases require such complex reconstruction. Similar studies in the recent literature have also been limited to smaller cohorts due to the specialized nature of these cases. Second, the follow-up period in our study (a minimum of 1 year) is relatively short for detecting long-term recurrences or late complications, compared to some other series.

Conclusion

Early primary fascial closure remains the most effective strategy in OA management, consistently yielding the lowest complication rates and best long-term outcomes. When early closure is not feasible, anterior component separation provides a reliable intermediate option, while transversus abdominis release is reserved for late or complex cases but carries increased morbidity. Skin-only closure is necessary in selected unstable patients but predictably results in planned ventral hernia requiring later reconstruction. These findings highlight the importance of algorithm-based, timing-dependent decision- making aligned with contemporary guidelines to optimize patient outcomes.

References

1. Björck M, Kirkpatrick AW, Cheatham M, et al. Amended classification of the open abdomen. Scand J Surg. 2016;105(1):5-10. doi:10.1177/1457496916631853.
   Article PubMed Google Scholar
2. Anastasiu M, Şurlin V, Beuran M. The management of the open abdomen - A literature review. Chirurgia (Bucur). 2021;116(6):645-56. doi:10.21614/ chirurgia.116.6.645.
   Article PubMed Google Scholar
3. Coccolini F, Roberts D, Ansaloni L, et al. The open abdomen in trauma and non- trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7. doi:10.1186/ s13017-018-0167-4.
   Article PubMed Google Scholar
4. Ottolino P. Managing the open abdomen: selecting an appropriate treatment strategy. Adv Wound Care (New Rochelle). 2024;13(8):400-15. doi:10.1089/ wound.2023.0121.
   Article PubMed Google Scholar
5. Boele van Hensbroek P, Wind J, Dijkgraaf MG, Busch OR, Goslings JC. Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg. 2009;33(2):199-207. doi:10.1007/s00268-008-9867-3.
   Article PubMed Google Scholar
6. Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39(4):912-25. doi:10.1007/s00268-014-2883-6.
   Article PubMed Google Scholar
7. Kääriäinen M, Kuuskeri M, Helminen M, Kuokkanen H. Greater success of primary fascial closure of the open abdomen: a retrospective study analyzing applied surgical techniques, success of fascial closure, and variables affecting the results. Scand J Surg. 2017;106(2):145-51. doi:10.1177/1457496916665542.
   Article PubMed Google Scholar
8. Coccolini F, Biffl W, Catena F, et al.The open abdomen, indications, management and definitive closure. World J Emerg Surg. 2015;10:32. doi:10.1186/s13017- 015-0026-5.
   Article PubMed Google Scholar
9. Poortmans N, Berrevoet F. Dynamic closure techniques for treatment of an open abdomen: an update. Hernia. 2020;24(2):325-31. doi:10.1007/s10029-020- 02130-9.
   Article PubMed Google Scholar
10. Moga D, Oprea V. Open anterior component separation for complex incisional and ventral hernias—When and how? Case series analysis. Indian J Surg. 2024;86(2):392-7. doi:10.1007/s12262-022-03516.
    Article PubMed Google Scholar
11. Rabie M, Abdelnaby M, Morshed M, Shalaby M. Posterior component separation with transversus abdominis muscle release versus mesh-only repair in the treatment of complex ventral-wall hernia: a randomized controlled trial. BMC Surg. 2022;22(1):346. doi:10.1186/s12893-022-01794-7.
    Article PubMed Google Scholar
12. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204(5):709-16. doi:10.1016/j.amjsurg.2012.02.008.
    Article PubMed Google Scholar
13. Zosa BM, Como JJ, Kelly KB, He JC, Claridge JA. Planned ventral hernia following damage control laparotomy in trauma: an added year of recovery but equal long-term outcome. Hernia. 2016;20(2):231-8. doi:10.1007/s10029-015- 1377-2.
    Article PubMed Google Scholar
14. Zahid MJ, Hussain M, Kumar D, et al. A descriptive analysis of skin-only closure and Bogota bag techniques for achieving complete fascial closure in damage control abdominal surgery. BMC Surg. 2024;24(1):192. doi:10.1186/ s12893-024-02484-2.
    Article PubMed Google Scholar
15. Seternes A, Rekstad LC, Mo S, et al. Open abdomen treated with negative pressure wound therapy: indications, management and survival. World J Surg. 2017;41(1):152-61. doi:10.1007/s00268-016-3694-8.
    Article PubMed Google Scholar
16. Piccoli M, Agresta F, Attinà GM, Amabile D, Marchi D; “Complex abdominal wall study” Italian Collaborative Group. “Complex abdominal wall” management: evidence-based guidelines of the Italian Consensus Conference. Updates Surg. 2019;71(2):255-72. doi:10.1007/s13304-018-0577-6.
    Article PubMed Google Scholar
17. Willms AG, Schwab R, von Websky MW, et al. Factors influencing the fascial closure rate after open abdomen treatment: results from the European Hernia Society (EuraHS) Registry: surgical technique matters. Hernia. 2022;26(1):61-73. doi:10.1007/s10029-020-02336.
    Article PubMed Google Scholar
18. Soliman F, Carlson GL, McWhirter D. Management of the open abdomen. Br J Surg. 2024;111(1):341. doi:10.1093/bjs/znad341.
    Article PubMed Google Scholar
19. Ribaldi S, Puzzovio A, Scarno F. The open abdomen: indications and techniques. In: Chiara, O, editors. Trauma centers and acute care surgery. Updates Surg. Springer, Cham. 2021.p.145-53.
    PubMed Google Scholar

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