The ideal temporary abdominal closure device should be universally available, be easy to apply, control fluid losses, leave the skin and fascia intact, not react to viscera, and be easy to change [14]. The first generation of temporary abdominal closures included towel clips to the skin and the use of synthetic materials to bridge the abdominal defect. Towel clips were certainly quick and easy to apply, but did not prevent abdominal compartment syndrome or fascial retraction, and interfered with postoperative radiologic evaluation of the abdomen. The use of a sterile crystalloid bag (i.e., a Bogota bag), synthetic mesh, or Velcro (i.e., the Wittmann Patch^®, NovoMedicus, Nokomis, FL) were and are commonly used. These devices help to prevent abdominal compartment syndrome, but do not allow for the control of fluid loss and nor do they prevent fascial retraction.

Second-generation temporary abdominal closure devices focus on all of the above with a primary focus on fluid control. The vacuum pack was one such device that covered the viscera with a plastic drape followed by a surgical towel. Sump drains were then placed over the towel and the laparostomy wound covered with an adhesive drape [15]. Certainly, this device controlled the fluid losses better than first generation devices, but it did not prevent loss of abdominal wall domain. The most commonly employed devices now are negative pressure wound therapy devices (i.e., the Wound V.A.C.^®, KCI, San Antonio, TX; and the Renasys™, Smith & Nephew, London, United Kingdom). These devices use negative pressure to both control fluid loss and to prevent retraction of the abdominal wall. Unfortunately, no device currently available meets all of the ideal criteria for a temporary abdominal closure device.

The right time to start thinking about closing an open abdomen is precisely when it is decided to leave an abdomen open. A step-wise, multifaceted approach to abdominal closure provides the surgeon with the best chance to close the abdomen as quickly as possible.

First, the decision to leave an abdomen open should be made with great caution. In Rotondo et al.’s paper coining the phrase “damage control,” only the most severely injured patients benefited from an open abdomen, not all patients. In fact, there is evidence that on-demand laparotomy is as safe as planned relaparotomy, while saving health care dollars and operations [16]. By properly selecting those patients who require a damage control operation, morbidity, survival, and costs can be reduced [17, 18].

Second, the resuscitation strategy used for trauma and emergency surgery patients greatly affects the ability to close an open abdomen. One of the major factors in failure to close an open abdomen is intestinal edema. Permissive hypotension, early blood and plasma resuscitation, and limited crystalloid administration can prevent or minimize intestinal edema. Plasma has been shown to prevent and partially reverse the endothelial dysfunction that leads to capillary permeability and interstitial edema [18, 19]. Excessive crystalloid administration leads directly to intestinal edema and has in fact been found to be an iatrogenic cause of abdominal compartment syndrome [20–29].

Third, proper selection of a temporary abdominal closure device can assist in preventing loss of abdominal wall domain. Negative pressure wound therapy appears to help prevent fascial retraction and is associated with increased likelihood of early fascial closure [25]. Additionally, there are many institution-specific pathways for abdominal closure that focus on constant tension on the fascia and repetitive, partial fascial closure.

Reported useful adjuncts for facilitating early fascial closure include the use of hypertonic saline to decrease bowel edema and third spacing, and early enteric feeding to decrease bowel distension [21, 22]. In addition, the early short-term use of neuromuscular blocking agents has been associated with more rapid and frequent primary fascia approximation in patients managed with damage control laparotomy [23].

When primary fascia approximation is not feasible, the skin may be closed directly over the granulation tissue covering the bowel. If skin approximation is not possible, a split thickness skin graft may be fixed over the granulation bed. Delayed abdominal wall reconstruction is then considered after 6 months. The early reconstruction utilizing bridging techniques and biologics has been associated with recurrence rates up to 80% and can potentially increase complications like small bowel fistula [26, 28]. The delayed abdominal wall reconstruction can be accomplished with a sandwich technique of mesh reinforcement in conjunction with the separation of components to restore a functional abdominal wall with acceptably low hernia recurrence rates [27]. In large defects not amenable to separation of components, bridging with nonabsorbable mesh is appropriate at this time. In select patients, early definitive fascia approximation can be obtained with separation of components in lieu of skin closure or split thickness skin graft during initial hospitalization. Endoscopic component separation techniques offer a minimally invasive alternative to open techniques, thus reducing the complications associated with large skin flaps communicating directly with contaminated spaces [29].

Although the use of damage control can be a life-saving maneuver in select patients, a surgeon should be well versed in the complications associated with the open abdomen.