The Open Abdomen: Balancing Pathophysiologic Benefits and Risks in the Era of Improved Resuscitation Practices

Surgeons leave the abdomen open for anatomical, physiological, and logistical reasons. Physiological derangements after damage control laparotomy are largely related to perfusion/systemic inflammatory disturbances induced by acute bowel injury and intra-abdominal hypertension (IAH). Importantly, both of these derangements are made worse by large-volume crystalloid fluid resuscitation. Potential physiologic benefits of the open abdomen (OA) have long been hypothesized to include prevention or improvement of the adverse effects of abdominal compartment syndrome (ACS). The OA also prevents the more subtle consequences of IAH, facilitates use of active negative pressure peritoneal therapy (which may improve the peritoneal and systemic inflammatory response), allows for delayed reconstructive options when abdominal domain has been lost, and permits planned abdominal re-exploration to remove sponges and reestablish intestinal continuity. However, the survival benefit of damage control (DC) laparotomy has recently been questioned because of the introduction of improved resuscitation practices (such as DC resuscitation and the avoidance of large-volume crystalloid fluid resuscitation) and the risks associated with open abdominal management, including progressive abdominal visceral edema, loss of abdominal domain, massive ventral hernias, enteric leaks, and enteroatmospheric fistulae. As equipoise begins to dwindle regarding the effectiveness and safety of liberal use of damage control laparotomy in the modern era of improved resuscitation practices, randomized evidence is increasingly required to elucidate the situations in which the associated benefits of open abdominal management outweigh the risks.