What are the management strategies for preventing complications in a patient with an open abdomen?

Management Strategies for Preventing Complications in Open Abdomen

Early abdominal wall closure and protective measures are essential for preventing complications in patients with an open abdomen, with fascial closure attempted as soon as the patient can physiologically tolerate it. 1

Understanding Open Abdomen Complications

Open abdomen (OA) management, while life-saving in certain situations, carries significant risks of complications that increase morbidity, mortality, length of hospital stay, and healthcare costs 1.

Major complications include:

• Entero-atmospheric fistula (EAF) formation 1
• Frozen abdomen (fixed/adherent bowel) 1
• Intra-abdominal abscesses 1
• Loss of abdominal domain 1
• Failure to achieve fascial closure 1

Preventive Strategies for Open Abdomen Complications

Early Fascial Closure

• Attempt primary fascial closure as soon as the patient can physiologically tolerate it 1
• Perform re-exploration within 24-48 hours after index operation, shortening this interval in cases of hemodynamic instability 1
• Utilize negative pressure wound therapy with continuous fascial traction as the preferred temporary abdominal closure technique 1

Prevention of Entero-Atmospheric Fistula and Frozen Abdomen

• Protect exposed bowel with plastic sheets, omentum, or skin 1
• Avoid direct application of synthetic prosthesis over bowel loops 1
• Avoid direct application of negative pressure wound therapy (NPWT) on viscera 1
• Bury intestinal anastomoses deep under bowel loops 1
• Break down adhesions gently during re-exploration to prevent progression to grade 2 or higher OA 1

Fluid and Hemodynamic Management

• Avoid fluid overload and vasopressor abuse 1
• Use hypertonic crystalloid and colloid-based resuscitation to decrease resuscitation-induced IAH 1
• Prefer frequent, small-volume fluid boluses over high-rate maintenance fluid infusions 1
• Monitor cardiac output continuously, targeting low/normal values 1
• Balance inotrope infusion based on patient condition and surgical procedures 1
• Consider volumetric-based monitoring technologies for accurate hemodynamic evaluation 1

Temporary Abdominal Closure Techniques

• Use negative pressure wound therapy with continuous fascial traction as the preferred technique 1
• Consider temporary abdominal closure without negative pressure (e.g., Bogota bag) only in low-resource settings, accepting higher complication rates 1
• For trauma patients, NPWT with fluid instillation may improve outcomes in terms of early and primary closure 1

Management of Established Complications

Entero-Atmospheric Fistula Management

• Tailor management according to patient condition, fistula output, position, and anatomical features 1
• Increase caloric intake and protein supplementation to meet elevated metabolic demands 1
• Isolate fistula effluent by separating the wound into different compartments 1
• Apply NPWT to make effluent isolation feasible and promote wound healing 1
• Delay definitive fistula management for at least 6 months until patient and wound have completely healed 1

Frozen Abdomen Management

• Prevent progression from grade 1 to grade 2 OA by gently breaking down adhesions during re-exploration 1
• For grade 2A (clean OA with developing adhesions), attempt to convert back to grade 1 if possible 1
• For grade 2B (contaminated OA with adhesions), focus on controlling contamination and preventing progression to grade 3-4 1
• For grade 3-4 (fistula formation and/or frozen abdomen), protect fascia and skin from deterioration and plan for complex reconstruction at 6-12 months 1

Definitive Abdominal Wall Reconstruction

• Avoid synthetic mesh (polypropylene, PTFE, polyester) for definitive closure after OA 1
• Consider biologic meshes for definitive abdominal wall reconstruction with large wall defects 1
• Components separation technique, mesh reinforcement, or bridging of fascial defect with mesh and perforator-saving skin undermining can be utilized in final closure 2

Common Pitfalls to Avoid

• Delayed abdominal closure (>24-48 hours) in trauma patients, which decreases fascial closure rates and increases complications 3
• Liberal use of open abdomen without clear indications 1
• Relying solely on temporary measures without planning for definitive closure 4
• Failing to implement protective measures for exposed bowel 1
• Neglecting nutritional support in patients with entero-atmospheric fistulas 1

By implementing these preventive strategies and management approaches, the morbidity and mortality associated with open abdomen complications can be significantly reduced, improving patient outcomes and quality of life 1.