T R AUMA AND EME R GENCY CA R E 1259
treatment (possible reversal agents) for bleeding issues in this patient
population is illustrated in Table 3.  ment of TIC. Early hemorrhage control in either the operating or
nn RECOMMENDED APPROACH TO
TRAUMA-­INDUCED COAGULOPATHY
Traumatically injured patients should be expedited to the nearest
trauma center. Early evaluation for those at risk for needing MTP by
either the ABC score or shock index is critical to stay ahead of and
prevent or attenuate TIC. Adoption of and implementation of MTP
that mimics WB in a 1:1:1 ratio is key to reducing blood transfusion
and minimizing TIC. Utilization of the principles of DCR by limiting
the use of crystalloid, allowing permissive hypotension, and balanced
resuscitation of blood products will lead to a greater chance of sur-
vival. Warming fluids, warming resuscitation bays, and liberal use of
warm blankets will go far to limit the influence of hypothermia on the
development of TIC. Early identification of coagulation abnormali-
ties within minutes of arrival via ROTEM or TEG is key to truncat-
ing and preventing the development of TIC. Serial evaluations of the
coagulation via ROTEM or TEG for ongoing bleeding will tailor the
The Abdomen That Will
Not Close
Heidi N. Overton, MD, and Kent A. Stevens, MD, MPH
T he principle of damage control has changed the practice of
surgery dramatically over the past 2 decades and has become
one of the central and dominant practices in trauma and acute care
surgery. As a result, the morbidity and mortality associated with
abdominal compartment syndrome (ACS), dilutional coagulopathy,
hypothermia, acidosis, and a myriad of other resuscitative compli-
cations have been reduced dramatically. However, with all signifi-
cant advances come new challenges. With the widespread practice
of damage control surgery (DCS) and abbreviated laparotomy, sur-
geons must be prepared to manage an open abdomen with a tem-
porary abdominal closure (TAC) as well as the abdomen that will
not close.
This chapter reviews TAC techniques, management of patients
with an open abdomen (OA), subsequent definitive closure of the
abdomen, and long-­term reconstruction options in patients who
develop hernias resulting from OA management.
nn INDICATIONS FOR LEAVING THE
ABDOMEN OPEN
Initially described by trauma surgeons, DCS is among the most com-
mon reasons for leaving an abdomen open. It was originally reserved
for a maximally injured subset of patients, defined as those with (1)
at least one major vessel injury (e.g., inferior vena cava), (2) at least
two visceral injuries, and (3) profound shock. Early results from DCS
were very impressive. Survival for such maximally injured patients
jumped from 11% to 77%, and use of DCS subsequently spread to
less severely injured patients. However, many now believe that the
pendulum has swung too far, and, in some cases, the risks associated
with leaving the abdomen open outweigh the benefits. Thus, patient
selection is vital. In general, there are five distinct groups of patients
in whom the abdomen should be acutely left open.
1. Patients with or at risk of intraabdominal hypertension (IAH)
and subsequent ACS. This group includes patients undergo-
ing major elective operations as those who will require massive
resuscitation are at risk for primary ACS. Similarly, patients who
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resuscitation of blood products and/or cryoprecipitate in the treat-
interventional radiology suite will prevent the development of further
coagulopathy and minimize unnecessary transfusions.
Suggested Readings
Brohi K, Singh J, Heron M, et  al. Acute traumatic coagulopathy. J Trauma.
2003;54:1127–1130.
Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in pa-
tients with severe traumatic hemorrhage: a practice management guide-
line from the Eastern Association for the Surgery of Trauma. J Trauma
Acute Care Surg. 2017;82(3):605–617.
Cotton BA, Guy JS, Morris Jr JA, et  al. The cellular, metabolic, and sys-
temic consequences of aggressive fluid resuscitation strategies. Shock.
2006;26:115–121.
Napolitano LM, Cohen MJ, Cotton BA, et al. Tranexamic acid in trauma: how
should we use it? J Trauma Acute Care Surg. 2013;74(6):1575–1586.
Schroll R, Swift D, Tatum D, et  al. Accuracy of shock index versus ABC
score to predict need for massive transfusion in trauma patients. Injury.
2018;49(1):15–19.
require substantial resuscitation because of severe medical illness
or trauma that requires abdominal decompression are at risk for
secondary ACS and are included in this group.
2. Patients undergoing DCS. This group includes patients undergo-
ing DCS for massive abdominal trauma, such as a patient with a
gunshot wound through a major vessel (e.g., renal artery), a solid
organ (e.g., kidney), and multiple segments of bowel. Once the
major vessel injury and solid-­organ injury have been controlled
and spillage from the bowel injury contained, the patient may be
too unstable for reconstruction of the bowel and closure of the
fascia. In this case, DCS allows rapid truncation of laparotomy
before the patient enters the “lethal triad” of hypothermia, acido-
sis, and coagulopathy. Once the damage has been controlled, the
patient can be taken to the intensive care unit (ICU) for resusci-
tation and stabilization. It is important to decide on the need to
perform DCS early on in the operation. Predictors of a patient’s
need for DCS include: temperature below 34°C, pH less than 7.2,
estimated blood loss greater than 4 L, transfusion requirement of
more than 10 units of packed red blood cells, systolic blood pres-
sure less than 70 mm Hg, lactate levels greater than 5 mmol/L,
base deficit greater than −6 in patients older than 55 years or
greater than −15 in patients younger than 55 years, and/or pro-
thrombin time greater than 1.6. DCS may also be required in
patients undergoing elective general surgery with overwhelming
blood loss or unexpected intraoperative findings that require fur-
ther stabilization/resuscitation.
3. Patients whose fascia cannot be closed. This category includes
patients who may be physiologically stable but have swollen
abdominal contents from an ongoing resuscitation (e.g., DCS) or
loss of fascial domain such that they cannot be closed primarily.
Fig. 1 depicts a patient who required TAC while waiting for bowel
edema to resolve. The latter example must be kept open until
the patient is ready for a definitive closure with mesh or other
modalities.
4. Patients with severe intraabdominal infections or necro-
tizing fasciitis of the abdominal wall. This includes patients
with necrotizing pancreatitis, a soft-­tissue infection, or a large
amount of purulent material in the abdomen requiring repeated
washouts.
5. Patients having a planned repeat exploration or second-­look
surgery. These are patients with intraabdominal pathology that
require another laparotomy in the next 48 to 72 hours. For exam-
ple, a vascular surgery patient with mesenteric ischemia who
undergoes a small bowel resection, and 48 hours later, needs to be
reexplored to check for additional bowel ischemia.  
1260 The Abdomen That Will Not Close
FIG. 1 ABThera VAC system (Kinetic Concepts, Inc.) features a foam
that extends out laterally to assist in volume removal. (Courtesy KCI, an
Acelity Company.)
Once the decision has been made to leave the patient open, a TAC is
performed and the patient transported to the ICU for further manage-
ment. In some situations, such as with massive liver injury, the abdom-
inal viscera may be packed with laparotomy pads for direct pressure
to control bleeding prior to a TAC. As stressed previously, the practice
of closing the fascia under tension must be avoided to prevent IAH
and ACS and to prevent wound complications that arise from ischemia
and pressure such as infection and dehiscence. For hemodynamically
stable patients who present challenges to primary abdominal closure
during the index case, several options to achieve a tension-­free abdom-
inal closure exist, some of which are highlighted later in this chapter.  Figs. 1–3 illustrate the ABThera VAC device (Kinetic Concepts
nn TEMPORARY ABDOMINAL CLOSURE
Once the decision to leave the abdomen open has been made, the
most optimal TAC technique as allowed by local resources should be
used. The ideal method for TAC should prevent loss of domain, limit
contamination, allow egress of peritoneal fluid, and avoid adhesion
formation. Many TAC techniques have been described in the 20-­plus
years since Rotondo and Schwab coined the term damage control sur-
gery, and all share the following attributes:
nn Easily encompasses the bowel and abdominal viscera
nn Allows enlargement of the abdominal cavity in situations of mas-
sive bowel, tissue, or retroperitoneal edema without inducing IAH
and while preventing ACS
nn Is expansible but also sturdy enough to permit the tamponade
effect of packing the liver or other bleeding surfaces
nn Does not damage the fascia and prevents fascial retraction
nn Contains and quantifies fluid loss
nn Prevents adhesions formation between viscera and abdominal
fascia
nn Promotes removal of infectious materials
nn Is quick to apply and remove
nn Has a good primary fascial closure rate (65% in a systematic
review of trauma-­only series by van Hensbroek et al.)
  
Options can be divided into skin approximation techniques (towel
clip closure, the Bogota bag, the silo technique), fascial closure tech-
niques using an interposition graft material sutured to the abdominal
fascia (e.g., the Wittmann Patch), or negative pressure wound therapy
(NPWT) (Barker’s vacuum pack, commercially available vacuum-­
assisted closure [VAC] devices). Table 1 compares the most common
methods of TAC.
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Although the earliest forms of TAC, the towel clip and Bogota bag
closures, are mentioned in the table, these have largely been replaced
with improved techniques. The 2014 International Consensus Confer-
ence on Open Abdomen in Trauma recommends NPWT whenever
feasible. These devices create a negative pressure silo that contains the
abdominal contents, is somewhat expansible, and enables measurable
fluid removal. The negative pressure is applied medially up through
the open abdomen, minimizing fascial retraction and loss of abdomi-
nal domain. These dressings are also very quick and easy to apply and
they can be used in situations of massive bowel swelling. Although
several variations of the negative-­pressure TACs exist, most include
the following key features.
1. Semipermeable (fenestrated), nonadherent inner membrane.
The innermost layer of fenestrated plastic or plastic-­ covered
sponge acts to protect the viscera from the overlying suction
device and simultaneously permit evacuation of intraabdominal
fluid.
2. Sponge inlay. The middle layer of the VAC device consists of a
porous sponge, often made of polyurethane, placed in an inlay
position between the fascial edges and flush with the level of the
skin. This layer transmits the suction effect onto the inner mem-
brane to remove intraabdominal fluid. Suction effect on the inlay
sponge also produces wound contraction and gentle fascial edge
reapposition over time.
3. Adhesive impermeable outer layer. The outer layer of the VAC
dressing is an adhesive, impermeable layer used to create a seal
around the edges of the wound and to anchor the dressing to the
periwound skin and allow gentle tension or wound contraction.
4. Suction device or machine. Finally, the suction device or
machine typically connects to the dressing via an adapter placed
overtop an intentionally created defect in the impermeable outer
layer to allow transmission of negative pressure directly onto the
middle sponge layer.
  
Inc.). Fig. 4 illustrates the Barker dressing, which uses materials read-
ily available in the operating room to create a vacuum pack dressing.
The World Society of Emergency Surgery also recommends NPWT
with continuous fascial traction as the preferred method for TAC but
acknowledges that TAC without negative pressure (e.g., Bogota bag)
can be applied in low-­resource settings accepting a lower delayed fas-
cial closure rate and higher intestinal fistula rate.
Practical Tips for Use of VAC Closure Dressing as
Temporary Abdominal Closure
Maximally Lateralize the Inner, Visceral Protective Layer
To prevent viscera from sneaking out at the edges of the inlay sponge, it
is important to maximally lateralize the inner, visceral protective layer.
This also prevents adhesions of the viscera to the undersurface of the
abdominal wall, which could make eventual abdominal closure more
difficult. It can be helpful to take down the falciform ligament as well as
any secondary adhesions to the anterior abdominal wall. One technique
is to use an abdominal wall retractor to facilitate adequate placement. 
Place Intestinal Anastomoses Deep in Abdominal Cavity
The previously mentioned 2014 International Consensus Conference
on Open Abdomen in Trauma found that OA and NPWT do not
harm intestinal anastomoses as long as they are buried deep within
the pelvis or central abdomen under multiple loops of bowel or out
laterally under the abdominal wall. 
Avoid Leaks
Air leaks, typically at the edges of the wound or at skin creases and
ostomy sites, are the Achilles heel of VAC therapy. Using an appro-
priate overlap of adhesive is important, as is intraoperative leak test-
ing before leaving the operating room. The use of ancillary liquid
 T R AUMA AND EME R GENCY CA R E 1261

TABLE 1 Various Methods of Temporary Abdominal Closure

Closure Technique Description Advantages Disadvantages
SKIN APPROXIMATION
Towel clip closure Serial application of towel clips or suture Rapid Does not prevent IAH; may
interfere with radiography or
angiography
Bogotá bag 3L IV bag, Steri-­Drape, Silastic bag, Inexpensive, inert, nonadherent Risk of evisceration, loss of ab-
plastic bag attached to skin dominal domain, risk for IAH;
fluid losses difficult to quantify
FASCIAL CLOSURE
Absorbable mesh Suturing of absorbable mesh to fascial Can be applied directly over bowel; al- Rapid loss of tensile strength (in
edges lows for drainage of peritoneal fluid the setting of infection), poten-
tially large-­volume late ventral
hernia; risk for bowel fistula;
damage to fascial edges from
repeated suturing
Wittmann patch Suturing of artificial burr (e.g., Velcro) Good tensile strength, allows for easy Poor control of third-­space fluid,
(Star Surgical) to fascia, staged abdominal closure by reexploration and eventual fascial adherence of bowel to abdomi-
application of controlled tension closure nal wall, potential for fistulas
NEGATIVE-­PRESSURE WOUND THERAPY
Barker’s vacuum Bowel covered with plastic sheet and Inexpensive, uses available materials; Difficult to quantify suction;
pack towel or laparotomy pads; flat drains moderate control of fluid; suction unknown whether full benefits
attached to wall suction and outer provides constant medial traction, of negative-­pressure therapy are
adhesive layer preventing loss of domain; high suc- realized
cess in fascial closure
VAC Abdominal Reticulated polyurethane foam dressing Increase in blood flow, a reduction on ab- Expensive; not available at all in-
Dressing System over the plastic covering of the bowel; dominal wall tension, reduction in size stitutions or in all low resource
negative pressure is controlled with a of the abdominal wall defect, decreased settings; mechanisms of action
computer-­controlled vacuum pump bowel wall edema, and potential re- not fully understood, but does
that applies a constant, regulated moval of inflammatory substances that lead to hyperossification; full
pressure to the wound surface and a accumulate in the abdomen during relationship to fistula needs
sensing device to prevent uncontrolled inflammatory states; edema and third-­ further study
fluid (e.g., blood) drainage space losses are controlled

IAH, Intraabdominal hypertension; IV, intravenous; VAC, vacuum abdominal closure.

FIG. 3 Vacuum-­assisted closure dressing on patient in the surgical

intensive care unit. This dressing was easily applied despite an extreme-
FIG. 2  Placement of innermost layer for the ABThera VAC (Kinetic ly swollen bowel and massive retroperitoneal bulging.
Concepts, Inc.), which combines with an embedded foam that fans out
laterally making it easier to apply and also assists in lateral paracolic
fluid and effluent removal.

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1262 The Abdomen That Will Not Close

A B C

D E

FIG. 4  Barker vacuum-­pack technique. (A) The polyethylene sheet is perforated multiple times with a scalpel blade. (B) The sheet is placed over
viscera and beneath the peritoneum/abdominal wall. (C) A moist towel is placed over the polyurethane and positioned below the skin edges. (D)
Suction drains are placed. (E) An outer adhesive dressing is applied, and the drains are hooked up to wall suction. (Courtesy Donald H. Barker, MD,
Department of Surgery, University of Tennessee, Chattanooga.)

adhesives, such as tincture of benzoin or Mastisol can facilitate a good
seal, especially in difficult areas for adhesion. Pulling and placing the
outer dressing under tension should be avoided as it can lead to epi-
dermal blistering leading to long-­term skin problems.  Appropriate Hole for Vacuum Device
Staples for Skin-­Sponge Apposition
Polyurethane sponge damages the epidermis when direct contact is
made under negative pressure; however, the inlay sponge must come
to a flush apposition with the skin edge to maximize the effectiveness
of the dressing. One solution is to use skin staples to temporarily affix
the inlay sponge to the edges of the wound during dressing applica-
tion and initial suction, although this is not a necessary step. These
staples then are removed at the next VAC dressing change.  based on clinical conditions and time of management. If active bleed-
Overlap Ostomies With Adhesive Outer Layer
VAC therapy in the presence of an ostomy creates a very difficult
problem for wound management. If the ostomy is close to the wound
or if the patient has an entero-­atmospheric fistula in the middle of
the wound, there are other possible solutions to insure a good seal
of the VAC dressing. With the ostomy appliance off, a sheet of adhe-
sive outer layer can be placed over the stoma site, with a small hole
cut to allow the stoma to pass through. The ostomy appliance then is
reapplied on top of the adhesive layer and simply changed every 48
hours with the dressing. 
Although simple, the use of an appropriately sized hole in the outer
adhesive layer is a critical step. At least a 2 × 2 cm hole is appropriate
and allows efficient transmission of negative pressure. 
Amount of Negative Pressure Depends on Clinical
Condition
The optimal therapeutic amount of negative pressure that maximizes
tissue growth is approximately 125 mm Hg, with some flexibility
ing caused by coagulopathy is suspected, the pressure level should
be lower, approximately negative 75 mm Hg, to decrease risk of
hemorrhage. 
nn OA POSTOPERATIVE CARE
After DCS, patients require management in a critical care unit with
aggressive hemodynamic monitoring. The immediate postoperative
period should consist of rewarming; correction of coagulopathy,

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acidosis, and metabolic derangements, and likely ongoing resus-
citation. During this early “fluid-­seeking” phase, patients should
not be restricted in terms of fluid administration because of con-
cerns about bowel edema or ultimate fascial closure. Hypertonic
crystalloid solutions for both infusion and bolus therapy during
the resuscitative phase may provide durable volume expansion
while restricting edema to a certain degree. All patients who sus-
tain penetrating abdominal wounds should receive a preoperative
dose of prophylactic, broad-­spectrum antibiotics. In the presence
of a hollow viscus injury, the literature supports use of prophylac-
tic antibiotics for not more than 24 hours. However, there is a lack
of evidence regarding the need to continue antibiotics solely in
patients with an OA. If the patient is thought to have sepsis, how-
ever, broad-­spectrum antibiotics should be initiated and narrowed
as appropriate based on culture results and clinical course. It should
be recognized that OA patients are in a hypermetabolic condition
and adequate nutritional support is mandatory. Early enteral nutri-
tion is preferred if the gastrointestinal tract is intact and viable. Fur-
ther goals for resuscitation are well delineated in the DCS literature
as well as in the chapter on damage control in this text. In brief, we
believe patients should receive judicious sedation and return to the
operating room every 24 to 72 hours for abdominal washout and
evaluation for abdominal closure.
Subsequent Take-­Backs to the Operating Room
At 1-­to 3-­day intervals, the patient should be returned to the oper-
ating room to irrigate the abdomen, change the abdominal VAC
dressing, and perform the necessary therapeutic maneuvers (e.g.,
bowel anastomosis, drainage of purulent collections) and to evalu-
ate for abdominal closure. At our institution, abdominal VAC dress-
ing changes are only done at the bedside if the patient is unstable
and cannot tolerate a trip to the operating room. Close collaboration
between the critical care team and the surgical team will allow for
early diuresis of eligible patients, and in turn, earlier abdominal clo-
sure. Data suggest that patients who remain open at day 8 are unlikely
to have a primary closure and are at increased risk for serious com-
plications, including wound infections and fistulas. Alternative clo-
sure techniques should be undertaken in these patients unless there
is some compelling reason to keep the abdomen open, such as the
continued need for fascial debridement.  tion of the abdominal wound, where the tension is highest in a stan-
Definitive Closure of the Abdomen
Once the patient is ready for abdominal closure, the best-­case sce-
nario is primary fascial closure. We generally place heavy, interrupted,
absorbable sutures in figure-­of-­8 fashion. In a setting of colonic per-
foration or heavy contamination, the skin should be left open. Some
authors suggest the use of retention sutures, but we do not routinely
place them. Retention sutures do not prevent fascial dehiscence but
can help prevent bowel evisceration should dehiscence occur. Addi-
tionally, they can be placed where wound infection and subsequent
dehiscence is a concern. It must be reiterated that the fascia must not
be closed under tension as this may lead to IAH and ACS.
Research on OA management has found that direct closure is
usually possible when the fascial edges are approximately 3 to 7 cm
apart. When this cannot be achieved, different surgical techniques
must be considered. Skin flaps can be raised to gain some medial
length in the fascia. The fascia can also be advanced by releasing the
lateral obliques; however, a full component separation is not recom-
mended for the acute closure of an open abdomen. For patients who
need mesh to bridge a gap between fascial edges, the options include
biologics such as human acellular dermal matrix (HADM), absorb-
able mesh such as Vicryl (Ethicon), and composite meshes. Two
possible techniques for management at this stage are outlined in the
following section.
If the fascia cannot be closed but the skin of the abdominal wall
is lax enough to close at the midline, an underlay biologic mesh can
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T R AU M A A N D E M E R G E N C Y C A R E 1263
be placed to bridge the fascial defect. The overlying skin can then be
closed to provide coverage for the mesh. In this situation, the method
of skin closure or reapproximation can be assisted by VAC therapy.
The underlay of biologic mesh typically is placed in an intraperitoneal
position and affixed to the abdominal wall using transfascial suture
techniques.
Where neither fascia nor skin has the capacity for midline clo-
sure, we routinely default to a temporary Vicryl (polyglactin) mesh
closure with delayed placement of a split-­thickness skin graft. This
temporary absorbable mesh then is placed in an underlay, intraperi-
toneal position. Standard saline moist to dry dressings are placed
twice daily for about 2 to 4 weeks until satisfactory granulation tis-
sue has appeared in the wound bed. At this time, a split-­thickness
skin graft can be placed to cover the wound. The patient should
be advised to avoid strenuous activity and heavy lifting during the
several months of convalescence, and an abdominal binder can be
considered for external support. Although this technique is neither
novel nor aesthetically or functionally appealing, it is a time-­tested
strategy to avoid OA catastrophes. With the advent of modern
abdominal wall reconstruction techniques, these patients now can
be offered a genuine and fairly reliable opportunity for restora-
tion of abdominal wall continuity, albeit at a later date once they
have completed convalescence for their acute illness. Usually this is
accomplished after a minimum of 6 to 12 months, allowing for soft-
ening of intraabdominal adhesions and recovery from what is likely
an extended stay in the ICU, hospital, and rehabilitation center. The
benefit of this approach is that the native abdominal wall muscula-
ture is not violated and remains intact, allowing a number of possible
interval definitive closure techniques. Fig. 5 describes an algorithm
for managing an open abdomen. 
Transfascial Tension-­Bearing Closure Techniques
A distinct alternative to standard closure for management of the
OA is a group of techniques collectively referred to as transfascial
tension-­bearing closure techniques. Typical examples of such clo-
sures include the standard Wittmann Patch of hook and loop (Vel-
cro) sheets and the Canica ABRA system. The guiding principle in
all such techniques is to redistribute abdominal wall tension to a
position lateral to the rectus sheath rather than in the medial por-
dard closure. In doing so, these techniques are postulated to produce
myofascial release by gradually lengthening the retracted oblique
and transversus abdominis myofascial groups to regain abdominal
domain.
The most recently described application of this technique has
been popularized by the trauma and acute care surgical group at
Cook County Hospital in Chicago and is known as the transabdomi-
nal wall traction (TAWT) method (http://www.starsurgical.com).
The TAWT technique takes advantage of a variation on the original
Wittmann Patch whereby the same hook and loop (Velcro) sheets are
used but are affixed lateral to the rectus sheath using heavy sutures
passed through all layers of the abdominal wall and fixed externally
by a hydrocolloid layer. The viscera beneath the hook and loop sheets
are protected by a semipermeable plastic adhesion barrier. This sys-
tem then can be tightened gradually during serial abdominal wash-
outs and adhesion barrier changes every 48 hours. The group at Cook
County Hospital reports great success with this technique and has a
near 100% rate of eventual abdominal closure, with only a relatively
small number on average of tightening and washout procedures. A
standard vacuum suction dressing is applied on top of the wound
between tightening procedures. Once a midline tension-­free closure
can be obtained with the TAWT system, a layered closure can be per-
formed either primarily or via a retrorectus approach. The rectorectus
space is developed and the posterior sheath is closed primarily. Then
a mesh can be placed in the retrorectus position before closure of the
anterior sheath and vacuum-­assisted management of the open cuta-
neous portion of the wound (Figs. 6 through 8). 
1264 The Abdomen That Will Not Close

Temporary Abdominal Closure

Resuscitate patient in Intensive Care Unit–increase body

temperature, correct electrolyte abnormalities and coagulopathies,
and monitor hemodynamic status. Plan take-back to the operating
room at 24-48 hours.

Safe fascial closure possible? No concern for intraabdominal

hypertension and no plans for additional abdominal operations?

Yes No

Primary fascial closure; using interrupted or running sutures. Continue temporary abdominal closure, continue resuscitation,
Leave the skin open versus closed based on wound diuresis when possible, re-operate at 48-72 hour intervals and
contamination and general physiologic state of patient. determine if fascial closure possible.

No
Yes

Patient unable to be closed by 8 days due to continuing critical

illness, bowel edema or loss of domain.

If able to close skin: place a biologic interposition graft to If unable to close skin: place temporary Vicryl mesh in
bridge the fascial defect intraperitoneal, underlay position

Split-thickness skin grafting once granulation tissue present

Complex ventral hernia repair at a later stage

FIG. 5 Algorithm for management of an open abdomen.

FIG. 6  Human acellular dermal matrix (AlloDerm) used as an interposition mesh where the fascia could not be primarily closed. Note that
the human acellular dermal matrix is placed, stretched, and sutured in as tautly as possible. (Courtesy Richard Redett, MD, Johns Hopkins Plastic and
Reconstructive Surgery, Baltimore, MD.)

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FIG. 7  Open abdomen after several days of a temporary abdomi-
nal closure, where the fascia cannot be primarily closed and a mesh
closure is required. (Courtesy Dr. Elliott Haut, Johns Hopkins Acute Care
Surgery, Baltimore, MD.)
FIG. 8  Large ventral hernia after closure of the fascia with Vicryl
mesh (Ethicon) and placement of split-­thickness skin graft. (Courtesy
Dr. Richard Redett, Johns Hopkins Plastic and Reconstructive Surgery,
Baltimore, MD.)
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T R AU M A A N D E M E R G E N C Y C A R E 1265
nn LONG-­TERM MANAGEMENT AND
DEFINITIVE ABDOMINAL WALL
RECONSTRUCTION
The development of a significant ventral hernia is common in long-­
term survivors of OA management. Although hernia development
is a risk factor regardless of the closure technique chosen for acute
management of an OA, a hernia is expected in patients closed with
an absorbable mesh and overlying skin graft. Careful planning is
required before attempting to repair these hernias, and the patient
must be completely recovered from the initial illness. The patient
should also be well-­nourished and physiologically optimized.
Another important aspect is to allow sufficient time for remodel-
ing of any adhesions that may have occurred between the mesh or
fascia and viscera. In the case of Vicryl mesh and subsequent skin
graft, one indicator of remodeling is the ability to pinch the mesh/
skin graft structure away from the underlying abdominal contents.
This separation indicates that the patient is ready for repair of the
ventral hernia. Many general surgeons will request assistance from
plastic surgeons, especially if tissue expanders or complex tissue rear-
rangement is required. The steps in reconstruction are:
1. Assess overlying skin and place tissue expanders, if necessary,
before surgery.
2. Excise the skin graft and any previously placed mesh.
3. Perform extensive lysis of adhesions to release viscera from over-
lying fascia.
4. Reapproximate fascia, which may require one or all of the
following:
a. Raise large skin flaps and dissect skin and subcutaneous tissue
from anterior fascia
b. Perform component separation, in which the aponeurosis of the
external oblique muscle is transected longitudinally bilaterally,
allowing the fascia to be pulled medially; the posterior sheath of
the recuts may be similarly transected to gain further length
c. Use of mesh; if the fascia does not come together, mesh can be
placed as an underlay (retrorectus position, above the posterior
rectus fascia or intraperitoneally with fascia overlap) or as an
interposition (bridging the fascial defect) graft; most authors
suggest the use of HADM or other biologics for this purpose
5. Onlay mesh on top of the fascia for reinforcement. If a HADM
underlay or interposition has been placed, we may also apply a
polypropylene mesh as an overlay. If no underlay was required,
a polypropylene may be placed as an onlay mesh to reinforce the
fascia.
6. Before skin closure drains can be placed in the subcutaneous
space to draw off accumulated fluid.
7. Standard primary skin closure with staples or a hybrid skin VAC
system as described by Soares and colleagues. 
nn SUMMARY
In the appropriately selected patient, an OA can serve as a lifesav-
ing component of an overall damage control strategy. Techniques to
achieve eventual closure of the OA should include balanced resuscita-
tion with crystalloid minimization, regular returns to the operating
room, and a carefully selected approach to closure based on patient,
surgeon, and institutional factors. Ongoing improvement in abdomi-
nal wall reconstructive techniques will continue to improve mortality
and quality of life for patients who require damage control surgery or
for those with ACS.
1266 Management of Vascular Injuries

1
2 1
5 2
3 5 3
4 4
A B

3 2 1

1
5 2
3
C 4 D

1
1 2
5 2
3 5 3
4 4
E F
FIG. 9  Component separation technique for the repair of large abdominal wall hernias. After entering the abdominal cavity, the bowels are dissect-
ed free from the ventral abdominal wall. (A) The skin and subcutaneous fat (1) are dissected free from the anterior sheath of the rectus abdominis
muscle (5) and the aponeurosis of the external oblique muscle (2). (B–C) The aponeurosis of the external oblique muscle (2) is transected longi-
tudinally about 2 cm lateral from the rectus sheath, including the muscular part on the thoracic wall, which extends at least 5 to 7 cm cranially of
the costal margin. (D) The external oblique muscle (2) is separated from the internal oblique muscle (3) as far laterally as possible. (E–F) If primary
closure is impossible with undue tension, a further gain of 2 to 4 cm can be reached by separation of the posterior rectal sheath from the rectus
abdominis muscle (5). Care must be taken not to damage the blood supply and the nerves that run between the internal oblique and transverse
muscles (4) and enter the rectus abdominis muscle at the posterior side. (From de Vries Reilingh TS, van Goor H, Rosman C, et al. Components separation
technique for the repair of large abdominal wall hernias. J Am Coll Surg. 2003;196[1]:32–37.)

Suggested Readings Chiara O, Cimbanassi S, Biffl W, et al. International consensus conference on

Barker DE, Green JM, Maxwell RA, et al. Experience with vacuum-­pack tem-
porary abdominal wound closure in 258 trauma and general and vascular
surgical patients. J Am Coll Surg. 2007;204(5). 784–492.
Boele van Hensbroek P, et al. Temporary closure of the open abdomen: a sys-
tematic review on delayed primary fascial closure in patients with an open
abdomen. World J Surg. 2009;33:199–207.
Campbell A, Chang M, Fabian T, et al. Management of the open abdomen:
from initial operation to definitive closure. Am Surg. 2009;75(suppl
11):S1–S22.
open abdomen in trauma. J Trauma Acute Care Surg. 2016;80(1):173–183.
Coccolini F, Roberts D, Ansaloni L, et al. The open abdomen in trauma and
non-­trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7.
Goldberg SR, Anand RJ, Como JJ, et al. Prophylactic antibiotic use in penetrat-
ing abdominal trauma: an Eastern Association for the Surgery of Trauma
practice management guideline. J Trauma Acute Care Surg. 2012;73(5 suppl
4):S321–S325.
Soares KC, et al. Novel wound management system reduction of surgical site
morbidity after ventral hernia repairs: a critical analysis. Am J Surg. 2015;
209:­324–332.

Management of remain associated with significant morbidity and mortality. The gen-
eral principles of trauma resuscitation are addressed elsewhere in this

Vascular Injuries book. This chapter will focus on evaluation and management issues
specific to injuries of major blood vessels of the neck, chest, abdomen,
pelvis, and extremities.
Andrew Schulick, MD, MBA, FACS
nn INITIAL EVALUATION

T he management of vascular injuries is determined by both the

location and the nature of damage as well as the presence of
associated trauma. Despite advances in care, major vascular injuries
Hard signs of vascular injury include (1) pulsatile bleeding; (2)
expanding hematoma; (3) the presence of a bruit or thrill; and (4)
evidence of ischemia, including the six P’s (pain, pallor, paresthesias,

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