A term commonly used by surgeons for the treatment of major trauma cases and abdominal compartment syndrome is "open abdomen." (This term may also be used on someone with another type or surgery such as an aortic aneurysm repair, but most commonly it refers to trauma.) This term means that the surgeon operated on a patient's abdomen and did not sew them back shut because they already had IAH or ACS and needed to be decompressed, they had so much swelling in their abdomen that they could not tuck the guts back in, or they were afraid that if they did tuck the guts back in, the patient would develop abdominal hypertension and possibly abdominal compartment syndrome. A common belief is that because the abdomen is left open, the patient cannot develop IAH or ACS

Figure 1: This patient has an IAP of 33 mm Hg – he is suffering from organ dysfunction due to abdominal compartment syndrome and needs a decompressive laparotomy.[1]

Figure 2: This is the patient from figure 1 after his decompressive Laparotomy. Note how dramatically the swollen intestines have bulged out of the abdominal incision. You can imagine how this swelling led to a dramatic increase in the IAP when the abdominal wall confined it. Now that it has been decompressed, the patient's IAP has dropped to 15 mm Hg.

The result of a decompressive laparotomy, or of simply leaving the abdomen "open" after a surgical case is that the volume of space available for the abdomens contents is much larger – probably half again as large. Once the abdomen is opened, the patients intestines are not left out in the open air because this would result in them drying out and dying as well as becoming infected by the external environment. For this reason, every "open abdomen" is closed with a dressing.

Dressing closures are done in a variety of ways: Bogota bag, Ioban dressing, Wittman patch, KCI Vac-pac, etc. One of the more common methods is using a "Bogota bag" because it costs almost nothing.

Figure 4: A Bogota bag is simply a 3 liter IV plastic bag with 3 of the edges cut off so it lies flat (Figures 3 & 4) It is put in a sterilizer in the operating room, then given to the surgeon who stitches it over the guts to the sides of the abdominal incision. This allows the clinician to be able to look through the clear window of the plastic bag and see if the guts are healthy. Sometimes they pack gauze under the bag to absorb fluid. The other methods are variations on the same theme, some including suction that allows re-accumulated fluid to be suctioned out of the abdominal cavity.

Figure 5: A commercially available temporary abdominal wall with Velcro to allow gradual wound tightening

Figures 6a & 6b: KCI Vac-Pac – Sponge inserted over an internal dressing, with suction in center, then covered again with outer dressing. 6a is early in the course when abdomen is still widely open. 6b is later as the wound is partially closed and the sponge is trimmed smaller.

The point of all the above discussion is this: There is no such thing as an open abdomen after surgery. This would lead to desiccation (drying/mummification) and death of the bowel plus internal infection. ALL open abdomens are closed with an airtight dressing for protection. The result is a closed abdomen that has a larger volume that the previous abdomen so the internal pressure is reduced.

However, the same processes that led to the accumulation of fluid and increase in IAP in the first place are still present. If they continue and further edema develops, the pressure within the abdomen can easily begin rising again and ACS can recur. This has been described in many reports. The largest series, by Gracias demonstrated that of all patients who had their abdomen left open to prevent IAH / ACS and had a vacuum pack placed to suction out excess fluid, still developed ACS (defined as IAP > 25 mmHg plus organ dysfunction).[2] The mortality in those who developed ACS was 60% while it was only 7% in the others.

The authors recommend that "treatment of IAH can be achieved by incising the external antimicrobial drape to allow for further expansion of the abdominal wall … Prior to placement of a new sterile drape."[2]

Their conclusion: "Management of the open abdomen with the vacuum-pack closure technique does not obviate against the development of ACS. … Ongoing vigilant monitoring of IAP is mandatory in this patient population to recognize IAH and treat it expediently."[2]

More recent data out of Colombia confirm Gracia's observations:  In a series of 79 open abdomens who were all serially monitored for IAP from the time of surgery through their ICU stay, Ordonez et al found recurrent abdominal compartment syndrome occurring in 8.9% of their study population - all who required emergent reexploration and relief of the elevated pressure despite having an "open" dressing.[3] The subgroup of patients who developed recurrent ACS suffered a 78% mortality while those who did not had a 20% mortality. Based on the enorous costs occuring when the patient is opened and the ability to monitor and prevent ACS in many patients, these clinicians feel aggressive bladder pressure monitoring of all open abdomens and early intervention to reduce rising pressures is mandatory to avoid death and reduce costs.

1. Balogh, Z. and F.A. Moore, Recent advances in the characterization of post-injury abdominal compartment syndrome. International J Intensive Care, 2004. 11(1): p. 30-42.
2. Gracias, V.H., et al., Abdominal compartment syndrome in the open abdomen. Arch Surg, 2002. 137(11): p. 1298-300.
3. Ordonze, C, Ramirez O, Ospina-Tascon G, et al: Survival of trauma patients with tertiary abdominal compartment syndrome after damage control laparotomy with open abdomen. Acta Clin Belg, 2009 64(3): p 125 abstract 157.