REVIEW ARTICLE

Total management
of the open abdomen
Demetrios Demetriades

Demetriades D. Total management of the open abdomen. Int Wound J 2012; 9 (Suppl. 1):17–24

ABSTRACT
The management of complex abdominal problems with the ‘open abdomen’ (OA) technique has become a
routine procedure in surgery. The number of cases treated with an OA has increased dramatically because of the
popularisation of damage control for life-threatening conditions, recognition and treatment of intra-abdominal
hypertension and abdominal compartment syndrome and new evidence regarding the management of severe
intra-abdominal sepsis. Although OA has saved numerous lives and has addressed many problems related to
the primary pathology, this technique is also associated with serious complications. New knowledge about the
pathophysiology of the OA and the development of new technologies for temporary abdominal wall closure (e.g.
ABThera™ Open Abdomen Negative Pressure Therapy; KCI USA Inc., San Antonio, TX) has helped improve the
management and outcomes of these patients. This review will merge expert physician opinion with scientific
evidence regarding the total management of the OA.
Key words: Abdominal compartment syndrome • Damage control • Negative pressure therapy • Open abdomen

INDICATIONS FOR THE OPEN
ABDOMEN
There are three major indications for the use of
the open abdomen (OA) technique: (i) damage
control for life-threatening intra-abdominal
bleeding, (ii) prevention or treatment of intra-
abdominal hypertension (IAH) and (iii) man-
agement of severe intra-abdominal sepsis (1,2).
Although the indications and timing of man-
agement of these conditions have changed
significantly in the last few years, a complete
description is beyond the scope of this paper.
Damage control should be planned and exe-
cuted early, before the patient reaches the
‘extremis’ stage (defined by coagulopathy,
hypothermia <35◦ C, and severe acidosis with
base deficit >15 mmol/l) taking into account
the nature of the injuries, the physiologic
Author: D Demetriades, MD, PhD, FACS, Department of
Surgery, Division of Trauma, Emergency Surgery and Surgical
Critical Care, University of Southern California, Keck School of
Medicine, Los Angeles, CA, USA
Address for correspondence: D Demetriades, MD, PhD,
FACS, Department of Surgery, Division of Trauma, Emergency
Surgery and Surgical Critical Care, University of Southern
California, Keck School of Medicine, 1510 San Pablo Street,
HCC 514, Los Angeles, CA 90033, USA
E-mail: demetria@usc.edu
parameters, any comorbidities and the expe-
rience of the surgeon. Attempts to restore com-
plex injuries, such as vascular or liver injuries,
in an unstable patient, should be avoided, in
favour of venous ligation, temporary arterial
shunting or gauze packing of the bleeding
area. Following damage control, the abdomen
should never be closed because of the risk
of IAH. The second stage in damage control
procedures involves stabilisation of the phys-
iological parameters in the intensive care unit
(ICU), followed by the final stage of definitive
surgical care in the operating room, usually
within 24–48 hours of the initial operation.
IAH can lead to tissue hypoperfusion, espe-
cially of the abdominal viscera, and organ
dysfunction. Uncontrolled IAH exceeding 25
mmHg can cause abdominal compartment syn-
drome (ACS), which is a potentially lethal
complication, characterised by cardiorespira-
tory and renal dysfunction, bacterial and toxin
intestinal translocation and intracranial hyper-
tension (1). It is essential that in high-risk
patients the intra-abdominal pressure is rou-
tinely monitored for early diagnosis and timely
therapeutic intervention. The monitoring is
usually done by bladder pressure measure-
ments, as part of standardised ICU protocols.

© 2012 The Author

International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc 17
 Open abdomen management
The role of the OA in the management
of severe secondary peritonitis has been a
controversial issue. There is strong clinical
evidence that temporary closure of the OA
using traditional passive dressings is of no
benefit and may be associated with increased
mortality and a higher incidence of enteroat-
mospheric fistulas when compared with the
closed abdomen and relaparotomy on demand
technique (3–5). However, recent work has
suggested that the OA technique with tem-
porary abdominal wall closure, using negative
pressure dressing methods, is associated with
positive outcomes (1,2,6–11).
METHODS FOR TEMPORARY
ABDOMINAL WALL CLOSURE
The technique used for temporary abdominal
wall closure can influence survival, complica-
tions and time to definitive fascial closure. The
ideal temporary abdominal closure method
should protect the abdominal contents, pre-
vent evisceration, allow removal of infected or
toxic fluid from the peritoneal cavity, prevent
the formation of fistulas, avoid damage to the
fascia, preserve the abdominal wall domain,
make reoperation easy and safe and facilitate
definitive closure (2,11–13). The materials and
techniques used for temporary closure have
A B
Figure 1. (A) Skin approximation with towel clips. (B) Bogota Bag. (C) Absorbable mesh that often extrudes from the wound and
results in an incisional hernia.
18
undergone a significant evolution over the last
decade and are described below.
Skin approximation with towel clips or
running suture has been used for a quick
abdominal closure, as part of damage control in
unstable patients. This technique is no longer
recommended as it has been shown to lead to
development of IAH or ACS (Figure 1A) (1,2).
The ‘Bogota Bag’ or silo is usually con-
structed using a 3-l sterile intravenous bag
or a sterile X-ray cassette cover, stapled or
sutured to the skin. This technique served an
important mission in the prevention or treat-
ment of IAH or ACS; however, the Bogota
Bag has now been abandoned by most modern
trauma centres in favour of new, more effective
methods. The Bogota Bag does not allow the
effective removal of excessive fluid in bowel
oedema or of toxin and cytokine-rich intra-
abdominal fluid. In addition, this technique
does not prevent the loss of abdominal wall
domain (Figure 1B) (14,15).
Absorbable synthetic meshes [Dexon™ (Tyco
Healthcare, North Haven, CT), Vicryl] have
been used by some surgeons to encourage
granulation tissue formation and subsequent
coverage with skin grafting. Synthetic meshes
play a limited role, because they may not
prevent IAH or ACS, do not effectively drain
effectively intra-abdominal fluid, and cannot
© 2012 The Author
International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc

be used in the presence of abdominal sepsis.
Synthetic meshes are also associated with a
high incidence of enteroatmospheric fistulas,
extrusion of parts of the mesh and a high
incidence of incisional hernia (Figure 1C) (1,2).
At present, negative pressure therapy (NPT)
techniques have become the most extensively
used methods for temporary abdominal wall
closure. NPT actively drains toxin or bacteria-
rich intraperitoneal fluid and has resulted in
a high rate of fascial and abdominal wall
closure. The two most commonly used NPT
techniques are Barker’s vacuum pack tech-
nique (BVPT) and Vacuum-Assisted Closure®
Therapy [V.A.C.® Abdominal Dressing Sys-
tem (ADS); KCI USA].
BVPT consists of a fenestrated, non adherent
polyethylene sheet that is placed over the
exposed bowel and under the peritoneum
and covered by moist surgical towels or
gauze. Two large silicone drains are then
placed over the towels, and the abdominal
wound is sealed with a transparent iodophor-
impregnated adhesive dressing. The drains
are connected to continuous wall suction at
100–150 mmHg (Figure 2A).
The V.A.C.® ADS is a sophisticated negative
pressure dressing system (Figure 2B), which
includes a polyurethane foam dressing that is
covered with a protective, non adherent layer,
tubing, a canister and a computerised pump. A
new generation of NPT (ABThera™ OA NPT;
Figure 2. (A) Example of Barker’s vacuum packing technique. (B) Example of the Vacuum-Assisted Closure® Abdominal Dressing
System.
© 2012 The Author
International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Open abdomen management
KCI USA Inc.) for use with the OA (Figure 3A)
provides a protective polyurethane foam layer
composed of six strut arms, embedded between
two fenestrated, non adherent sheets for
easier placement around the bowel and under
the peritoneum (Figure 3B). A second foam
dressing is placed over the protective foam
layer (Figure 3C) and covered with a semi-
occlusive adhesive drape (Figure 3D). A small
piece of the adhesive drape and underlying
foam are excised and an interface pad with
a tubing system is applied over this defect
and connected to an NPT unit (Figure 3E).
The negative pressure collapses the foam,
exerting medial traction and approximation of
the fascia and abdominal wall. A pump canister
collects and quantifies the fluid evacuated from
the abdomen. Dressing changes are usually
performed every 2–3 days. In the Figure 3 case
study, definitive closure was achieved 9 days
after the initial operation (Figure 3F).
Bench studies were conducted to determine
the distribution of negative pressure across
the ABThera™ OA NPT and BVPT dressings.
Results for the ABThera™ OA NPT showed
a relatively even distribution of negative
pressure in both the centre and the periphery
of the foam, facilitating effective removal of
any deep peritoneal fluid, reduction of bowel
oedema and approximation of the abdominal
wall wound (Figure 4A) (16). In contrast, with
BVPT the distribution of negative pressure is
19
 Open abdomen management

A B C

D E F

Figure 3. (A) Open abdomen. (B) Polyurethane foam with six strut arms, embedded between two fenestrated non adherent sheets
placed directly over the bowel and tucked under the peritoneum. (C) Perforated foam cut into size and shape is placed over the
protective foam. (D) The foam is covered by a semi-occlusive adhesive drape. (E) A small piece of the adhesive drape and underlying
foam are excised and an interface pad with a tubing system is applied over this opening and connected to an NPT unit. (F) Definitive
fascial and skin closure 9 days after the initial operation.

A B

Figure 4. (A) Distribution of negative pressure with ABThera™ open abdomen negative pressure therapy. (B) Distribution of
negative pressure with Barker’s vacuum pack technique. (Reprinted with permission from KCI Licensing, Inc.)

highly uneven, achieving fairly high negative
pressure in the centre and near zero pressure
in the periphery (Figure 4B) (16).
COMPLICATIONS OF THE OPEN
ABDOMEN
Although the OA has addressed some serious
and potentially lethal problems related to early
closure of the abdomen, this technique is
also associated with significant complications,
including fluid and protein loss, a catabolic
state, loss of abdominal wall domain and
development of enteroatmospheric fistulas
(Table 1). The most serious complication is the
formation of fistulas, which are difficult to
Table 1 Complications associated with the open abdomen
• Fluid and protein loss
• Catabolic state
• Loss of bowel function
• Enteroatmospheric fistulas
• Loss of abdominal wall domain
• Prolonged intensive care unit and hospital stay
• Increased hospital costs
control or repair. The overall incidence of
this complication is about 5% (17,18); how-
ever, in chronic OAs the incidence increases
to about 15% (19). The development of a fis-
tula increases the ICU stay by approximately
threefold, the hospital stay by approximately

© 2012 The Author

20 International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc

fourfold and the hospital charges by approxi-
mately 4·5-fold (20).
The most effective way to reduce the
complications associated with the OA is to
close the abdominal wall as soon as possible.
This can be achieved by a combination of
three strategies: (i) avoidance of excessive fluid
resuscitation, (ii) use of effective NPT dressings
for temporary abdominal wall closure and (iii)
use of biological materials in appropriate cases
for definitive fascial closure.
Restrictive fluid resuscitation in the critical
patient has now become the new standard of
care. Previous practices targeting ‘superopti-
misation’ or ‘supranormal’ cardiac function
parameters have been shown to have nega-
tive effects on the cardiorespiratory system,
and to promote bowel oedema and IAH (21).
Reduction of bowel oedema with a conserva-
tive fluid resuscitation increases the chances of
early definitive abdominal closure.
ENTEROATMOSPHERIC FISTULAS
The development of enteroatmospheric fistulas
is the most serious and challenging local
complication in an OA. The exposed bowel
is at risk of fistulisation, especially in a
chronic OA and in the presence of synthetic
meshes and infection. In some cases, numerous
enteroatmospheric fistulas may develop, and
the constant leak of enteric contents on the OA
aggravates the inflammation and encourages
the formation of new fistulas. Local control
of the fistula is extremely difficult because no
collection bag can be applied on the OA.
The management includes temporary local
control to prevent spillage of enteric contents
and prevent excoriation of the surrounding
skin while planning for definitive closure of
the fistula. Efforts to create a controlled fistula
by inserting a Foley’s catheter never succeed
and usually make the fistula larger. Attempts
to suture the fistula rarely succeed, unless the
repair is covered by normal skin or skin graft.
Appropriate use of NPWT via V.A.C.® Ther-
apy may be helpful in many cases and may
control the spillage of intestinal contents over
the surrounding exposed bowel (22). This tech-
nique cannot be used with V.A.C.® ADS and
ABThera™ OA NPT. In small fistulas, the neg-
ative pressure approximates the edges of the
fistula and spontaneous closure may occur. In
large fistulas, the NPWT system may allow
© 2012 The Author
International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Open abdomen management
a controlled diversion of the fistula contents
and protect the surrounding OA and normal
skin. There are various techniques to achieve
this diversion: The OA is covered by XeroForm
(Covidien, Mansfield, MA) dressing, leaving
the fistula orifices uncovered. A piece of foam is
applied over the abdominal defect and a small
hole is cut exactly over the fistula, followed by
application of the polyurethane adhesive drape
and connection to continuous negative suction.
Lastly, a 2-cm hole is cut on the drape and over
the fistula. An ostomy bag is then applied to
collect the effluent (22). A modification of this
technique includes insertion of a red rubber
catheter, or ‘rubber nipple’ over the opening
of the fistula. At a later stage, the area around
the fistula is skin grafted. A definitive surgical
repair is performed, ideally 4–6 months later.
TREATMENT GOALS/OUTCOMES:
DEFINITIVE FASCIAL CLOSURE
Following stabilisation of the patient, the goal is
early and definitive closure of the abdomen, in
order to reduce the complications associated
with the OA. Closure should be achieved
without tension or risk of recurrence of IAH.
Primary fascial closure may be possible in
many cases within a few days of the initial
operation, when any intra-abdominal packing
is removed and the bowel oedema subsides.
Previous work has suggested that the OA
technique with temporary abdominal wall clo-
sure using NPT as delivered by V.A.C.® ADS
or ABThera™ OA NPT, is associated with posi-
tive outcomes (1,2,6–11). Although some small
retrospective studies expressed concern about
the possibility of increased risk of enteroat-
mospheric fistulas with this technique, other
studies reported no increased risk (5,23,24).
Experimental work in a peritoneal sepsis
porcine model has shown that pigs treated
with NPT (−125 mmHg) had reduced mortal-
ity and organ dysfunction compared to animals
treated with traditional passive drainage. NPT
removed significantly more peritoneal fluid,
reduced systemic inflammation and improved
the histopathology in the intestine, lung, liver
and kidney (25).
More recently, Franklin et al. (11) reported
on a 19-patient case series documenting the
use of the ABThera™ OA NPT System for
management of the OA in non traumatic
surgery. The majority of patients had chronic
21
 Open abdomen management
diseases, prior abdominal surgeries and at
least one significant co-morbidity, such as
diabetes, hypertension or chronic renal failure.
Seventeen of the 19 patients (89·5%) achieved
fascial closure, which is consistent with
the reported rates using NPT, and the
Kaplan–Meier median time to closure was
6 days. Five patients (5/19; 26%) died during
their hospitalisation, which is below the 30%
mortality rate for an OA (26). The authors
concluded that this new NPT system was
successful in managing the OA of critically
ill patients (11).
Application of ABThera™ OA NPT may help
reduce the formation of adhesions between the
bowel and anterior peritoneum, prevent the
loss of abdominal domain and encourage the
approximation of the fascial edges towards
the midline. Experimental work using a swine
model of intestinal ischaemia and severe sep-
sis, showed that early application of NPT
prevented the development of IAH and subse-
quent multiple organ dysfunction syndrome,
when compared to treatment with passive
drainage (25). The suggested mechanism of
protection is the removal of the peritoneal
fluid containing inflammatory mediators, as
shown by the reduction of the concentration of
cytokines in the blood (25). These results have
not yet been confirmed in human studies.
In many patients, early definitive fascial
closure may not be possible because of
persistent bowel oedema or intra-abdominal
sepsis. In these cases, progressive closure
should be attempted at every return to the
operating room, by placing a few interrupted
sutures at the top and bottom of the fascial
defect. Other techniques used for progressive
fascial closure include a combination of NPT
with a temporary mesh, sutured to the fascial
edges. The mesh is tightened every few days,
until the fascial defect is dominated. At this
stage, the mesh is removed and the fascia is
closed primarily.
All described gradual fascial approximation
techniques may be used in combination with
NPT, including closure via velcro or zipper-
type synthetic materials (i.e. Wittmann Patch).
This technique preserves the abdominal wall
domain but does not allow effective drainage
of any intra-abdominal fluid. In addition, there
is a major concern that the sutures might cause
ischaemic damage to the edges of the fascia,
22 International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc
making the definitive closure operation more
difficult.
In patients with persistent large fascial
defects, bridging with biological material
should be considered. Biologics have numer-
ous advantages over synthetic materials. The
prosthesis is incorporated into the normal
tissues and becomes vascularised, is more
resistant to infections, does not need to be
removed if it gets infected, and maintains a
satisfactory tensile strength. Acellular matrix
materials, prepared from cadaver or animal
skin or animal intestine, are widely available
in the market. The material should always be
covered by skin, usually after creating skin
flaps by undermining the area lateral to the
defect.
NPT: CONTRAINDICATIONS/
WARNINGS
Pressure settings should be individualised per
patient. In cases with concerns about incom-
plete hemostasis, application of high negative
pressures may aggravate bleeding. In these
cases an initial low negative pressure is advis-
able. In addition, placing polyurethane foam
directly on bowel may cause fistula formation.
Extreme precaution must be taken to ensure
the foam is not in contact with the bowel.
Rather, a non adherent layer should be placed
completely over the bowel to protect it and
allow fluid egress. Also, although rare, IAH
may occur in some cases during temporary
abdominal wall closure. It is important that
postoperatively the bladder pressure is mon-
itored routinely during the first few hours of
negative pressure dressing application.
TECHNICAL PEARLS
The following are tips in the application
of NPT:
• No active intra-abdominal bleeding: start
with negative pressure at −125 mmHg.
• Suspicion of active bleeding due to coag-
ulopathy and not amenable to surgical
repair, consider starting with low pres-
sures, −25 to −50 mmHg, and closely
monitor output.
• Postoperatively, monitor for bleeding in
the canister.
• Postoperatively, monitor bladder pres-
sures for IAH.
© 2012 The Author

ECONOMIC VALUE AND FUTURE
DIRECTIONS
Studies and practice have shown that NPT
helps achieve early definitive abdominal wall
closure in many cases and may help reduce the
serious complications associated with the open
abdomen. In addition, prevention of incisional
hernias eliminates the need for another major
and costly operation. The concept of NPT
is a relatively new and exciting field, which
revolutionised the management of a complex
surgical problem. The role of the NPT in other
abdominal surgical pathologies, such as severe
sepsis or necrotising pancreatitis, needs to be
explored in future studies.
CONFLICTS OF INTEREST
Dr DD has a consulting agreement with
Kinetic Concepts, Inc. This article is part of
an educational supplement funded by Kinetic
Concepts Inc. to provide an overview of the
V.A.C. Therapy family of products for new
users in developing markets.
REFERENCES
1 Kaplan M, Banwell P, Orgill DP, Ivatury RR, Deme-
triades D, Moore FA, Miller P, Nicholas J,
Henry S. Guidelines for the management
of the open abdomen. Wounds 2005;17(1
Suppl):S1–S24.
2 Campbell A, Chang M, Fabian T, Franz M,
Kaplan M, Moore F, Reed RL, Scott B, Silver-
man R. Management of the open abdomen: from
initial operation to definitive closure. Am Surg
2009;75(11 Suppl):S1–S22.
3 Robledo FA, Luque-de-Leon E, Suarez R, Sanchez P,
de-la-Fuente M, Vargas A, Mier J. Open ver-
sus closed management of the abdomen in the
surgical treatment of severe secondary peri-
tonitis: a randomized clinical trial. Surg Infect
2007;8:63–72.
4 Christou NV, Barie PS, Dellinger EP, Waymack JP,
Stone HH. Surgical Infection Society intra-
abdominal infection study. Prospective evalu-
ation of management techniques and outcome.
Arch Surg 1993;128:193–9.
5 Adkins AL, Robbins J, Villalba M, Bendick P, Shan-
ley CJ. Open abdomen management of intra-
abdominal sepsis. Am Surg 2004;70:137–40.
6 Garner GB, Ware DN, Cocanour CS, Duke JH,
McKinley BA, Kozar RA, Moore FA. Vacuum-
assisted wound closure provides early fascial
reapproximation in trauma patients with open
abdomens. Am J Surg 2001;182:630–8.
7 Suliburk JW, Ware DN, Balogh Z, McKinley BA,
Cocanour CS, Kozar RA, Moore FA, Ivatury RR.
Vacuum-assisted wound closure achieves early
© 2012 The Author
International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Open abdomen management
fascial closure of open abdomens after severe
trauma. J Trauma 2003;55:1155–60.
8 Miller PR, Thompson JT, Faler BJ, Meredith JW,
Chang MC. Late fascial closure in lieu of
ventral hernia: the next step in open abdomen
management. J Trauma 2002;53:843–9.
9 Kaplan M. Negative pressure wound therapy in the
management of abdominal compartment syn-
drome. Ostomy Wound Manage 2004;50:(11A
Suppl):20S–5S.
10 Brace JA. Negative pressure wound therapy for
abdominal wounds. J Wound Ostomy Conti-
nence Nurs 2007;34:428–30.
11 Franklin ME, Alvarez A, Russek K. Negative
pressure therapy: A viable option for general
surgical management of the open abdomen. Surg
Innov. 2012 Jan 5. [Epub ahead of print].
12 Stonerock CE, Bynoe RP, Yost MJ, Nottingham JM.
Use of a vacuum-assisted device to facilitate
abdominal closure. Am Surg 2003;69:1030–5.
13 Vertrees A, Shriver C. Management of the open
abdominal wound. In: Sen CK, editor. Advances
in wound care, 1st edn. New Rochelle: Mary Ann
Liebert, Inc,2010:38–43.
14 Rutherford EJ, Skeete DA, Brasel KJ. Management
of the patient with an open abdomen: techniques
in temporary and definitive closure. Curr Probl
Surg 2004;41:821–76.
15 Aydin C, Aytekin FO, Yenisey C, Kabay B, Erdem E,
Kocbil G, Tekin K. The effect of different tem-
porary abdominal closure techniques on fascial
wound healing and postoperative adhesions
in experimental secondary peritonitis. Langen-
becks Arch Surg 2008;393:67–73.
16 Sammons A, Delgado A, Cheatham ML. In-vitro
pressure manifolding distribution evaluation of
the Abthera open abdomen negative pressure
therapy system, V.A.C. abdominal dressing
system, and Barker’s vacuum-pack technique,
conducted under dynamic conditions. [Abst P
078]. Poster presented at the Clinical Symposium
on Advances in Skin & Wound Care; 2009 Oct
22–25; San Antonio (TX), 2009.
17 Barker DE, Kaufman HJ, Smith LA, Ciraulo DL,
Richart CL, Burns RP. Vacuum pack technique
of temporary abdominal closure: a 7-year expe-
rience with 112 patients. J Trauma 2000;48:201–6.
18 Smith LA, Barker DE, Chase CW, Somberg LB,
Brock WB, Burns RP. Vacuum pack technique of
temporary abdominal closure: a four-year expe-
rience. Am Surg 1997;63:1102–8.
19 Teixeira PG, Salim A, Inaba K, Brown C, Browder T,
Margulies D, Demetriades D. A prospective look
at the current state of open abdomens. Am Surg
2008;74:891–7.
20 Teixeira PG, Inaba K, Dubose J, Salim A, Brown C,
Rhee P, Browder T, Demetriades D. Enterocuta-
neous fistula complicating trauma laparotomy: a
major resource burden. Am Surg 2009;75:30–2.
21 Balogh Z, McKinley BA, Cocanour CS, Kozar RA,
Valdivia A, Sailors RM, Moore FA. Supranormal
trauma resuscitation causes more cases of
abdominal compartment syndrome. Arch Surg
2003;138:637–43.
23
 Open abdomen management
22 Goverman J, Yelon JA, Platz JJ, Singson RC, Turci-
novic M. The ‘‘Fistula VAC,’’ a technique for
management of enterocutaneous fistulae arising
within the open abdomen: report of 5 cases.
J Trauma 2006;60:428–31.
23 Perez D, Wildi S, Demartines N, Bramkamp M,
Koehler C, Clavien PA. Prospective evaluation of
vacuum-assisted closure in abdominal compart-
ment syndrome and severe abdominal sepsis.
J Am Coll Surg 2007;205:586–92.
24 Wondberg D, Larusson HJ, Metzger U, Platz A,
Zingg U. Treatment of the open abdomen with
the commercially available vacuum-assisted
closure system in patients with abdominal
24 International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc
sepsis: low primary closure rate. World J Surg
2008;32:2724–9.
25 Kubiak BD, Albert SP, Gatto LA, Snyder KP, Maier
KG, Vieau CJ, Roy S, Nieman GF. Peritoneal
negative pressure therapy prevents multi-
ple organ injury in a chronic porcine sep-
sis and ischemia/reperfusion model. Shock
2010;34:525–34.
26 Boele van Hensbroek P, Wind J, Dijkgraaf MG,
Busch OR, Carel Goslings J. Temporary closure
of the open abdomen: a systematic review
on delayed primary fascial closure in patients
with an open abdomen. World J Surg 2009;33:
199–207.
© 2012 The Author