How to prevent impending perforation in an open abdomen?

Preventing Impending Perforation in Open Abdomen

Always use a large, fenestrated non-adherent interface layer placed as widely as possible inside the abdomen to protect exposed bowel and prevent fistula formation—this is the single most critical intervention to prevent perforation. 1

Critical Protection Strategy

The primary mechanism of preventing bowel perforation in open abdomen is proper application of a protective barrier between negative pressure wound therapy (NPWT) and the viscera:

• Place a non-adherent interface layer directly between the abdominal viscera and any wound filler or foam, extending it laterally into the paracolic gutters, cranially onto the diaphragm after taking down the falciform ligament, and caudally into the pelvic cavity 1
• Failure to apply this interface layer exposes patients to significant risk of fistula formation and bowel damage during dressing changes 1
• All commercial NPWT devices contain a dedicated interface layer as part of the kit that should be utilized 1

Preventing Progression to Perforation Risk

Early Closure Strategy

Aim for early definitive fascial closure within 4-7 days of initial laparostomy to prevent complications including fistula formation 1:

• Early closure is the foundation of preventing complications associated with open abdomen 1
• The window of opportunity for primary fascial closure is typically 7-10 days before fixity develops and the wound progresses to Grade 4 1
• Sequential dynamic closure techniques with NPWT should be applied to facilitate delayed primary closure while preventing lateral retraction 1

NPWT Application Technique

Use specialized foam-based NPWT systems rather than improvised methods 1:

• Commercial foam-based systems provide medial traction to prevent lateral retraction of the abdominal wall, which preserves domain and facilitates closure 1
• Apply continuous NPWT at pressures up to 80 mmHg 1
• The foam compresses under negative pressure, providing a "splinting effect" that prevents loss of domain 1

Minimizing Mechanical Trauma

Reduce frequency of dressing changes to minimize bowel manipulation 1:

• Fewer dressing changes significantly reduce risk of iatrogenic bowel injury 1
• Each dressing change represents an opportunity for inadvertent bowel damage if the interface layer is disrupted 1
• When using NPWT with proper interface layers, extended intervals between changes are safe for non-draining wounds 2

Grade-Specific Considerations

Grade 1-2 Open Abdomen (Early Phase)

Prevention of adhesion formation is paramount 1:

• The non-adherent interface layer reduces adhesions between exposed bowel and the abdominal wall, retaining the option for fascial closure 1
• Prevention of adhesions directly reduces risk of bowel damage and subsequent fistula formation 1
• Apply sequential dynamic closure techniques (zips, clips, resorbable meshes, Wittmann patch) in conjunction with NPWT to achieve 79% fascial closure rates 1

Grade 3 Open Abdomen (Fistula Present)

If fistula has already developed, isolate it to prevent extension 1:

• Visible fistulae can be managed with a floating stoma using an ostomy bag, with NPWT providing secure bag adhesion 1
• Provide a conduit from the fistula source through the dressing to prevent pooling beneath the foam 1
• NPWT can "splint" drainage tubes to keep them close to the fistula mouth while preventing bowel damage from tube dislodgement 1

Grade 4 Open Abdomen (Frozen Abdomen)

Avoid physical manipulation of adhesions at this stage 1:

• Once fixity is established, attempts to release adhesions are highly likely to result in major bowel lesions 1
• Use a wound contact layer (non-adherent silicone layer) between NPWT foam and the wound bed to protect delicate granulation tissue and underlying organs 1, 3
• Remove all non-absorbable meshes at this stage 1

Common Pitfalls to Avoid

Critical errors that increase perforation risk:

• Never apply NPWT foam directly to bowel without an interface layer—this is the most common cause of iatrogenic fistula formation 1
• Do not use surgical towels as wound filler (vac-pac technique)—they do not compress and provide limited splinting, increasing closure difficulty and prolonging open abdomen duration 1
• Avoid excessive manipulation during dressing changes—each manipulation increases risk of bowel injury 3
• Do not delay closure beyond 7-10 days without compelling reason—prolonged open abdomen significantly increases fistula risk 1
• Ensure accurate placement of wound filler within the wound rather than on surrounding skin to maintain proper negative pressure distribution 1

Adjunctive Protective Measures

Additional strategies to reduce perforation risk:

• Manage wound fluid actively with NPWT to prevent pooling of contaminated fluid that can cause tissue breakdown 1
• Consider incisional NPWT on closed incisions after fascial closure to prevent wound dehiscence and need for reopening 1
• Use NPT with continuous fascial traction for best results in achieving delayed fascial closure and reducing enteroatmospheric fistula risk 1