REVIEW

CURRENT
OPINION Abdominal compartment syndrome and the open
abdomen: any unresolved issues?
Michael Sugrue

Purpose of review
This article reviews the key principles of abdominal compartment syndrome and the open abdomen,
exploring some of the unresolved issues. It reviews new concepts in care.
Recent findings
Recent use of peritoneal resuscitation, and benefits of mesh-mediated traction are discussed. Abdominal
compartment syndrome remains a result of complex interaction between general haemorrhage, sepsis and
fluid resuscitation. Improved resuscitation and sepsis control has decreased but not abolished the need for
the open abdomen and progression for abdominal compartment syndrome. Fourth-generation abdominal
wall dressings need to be combined with a dynamic closure system; currently, negative pressure wound
therapy at the index open abdomen coupled with mesh-mediated tractions offers the best outcome.
Summary
The key to optimizing outcome is early abdominal closure within 7 days because failure to do so will
increase morbidity, mortality and fistulae formation. Novel techniques complementing existing
de-resuscitation techniques are discussed.
Keywords
abdominal compartment syndrome, abdominal wall closure, open abdomen

INTRODUCTION practice between enthusiastic trauma surgeons

The abdominal compartment syndrome (ACS), a
mystical entity dreamed up by a society or a real
patient killer? There are many who remain sceptical
about ACS and its existence. ACS is defined as a
sustained intra-abdominal pressure (IAP) greater
than 20 mmHg that is associated with new organ
dysfunction/failure [1]. It is beyond doubt that if
a patient’s IAP progressively rises through the
different grades of intra-abdominal hypertension
(IAH) (Table 1), particularly above 20 mmHg, organ
dysfunction is the usual and risk of death increases.
There are a number of unresolved issues relating
to ACS, in particular, which patients with increasing
IAH will progress to ACS. The role of both prophy-
lactic and therapeutic open abdomen and decom-
pression is still debated. It is currently not possible to
predict impending ACS and identify those who will
not benefit from aggressive medical strategy and
need abdominal decompression.
ACS had elicited a range of emotional names
called ‘a wolf in sheep’s clothing’, the ‘neglected
compartment syndrome’ and the ‘iatrogenic com-
partment syndrome’. It has polarized surgeons’
thought process, with unexplained variation in
and conservative upper gastro-intestinal-pancreatic
surgeons.
This article will explore ACS and issues relating
to IAP measurement, propose a pathway to both
prophylactic and therapeutic decompression and
reflect the latest in severe acute pancreatitis (Video
1, introductory comments, http://links.lww.com/
COCC/A14).
DEFINING THE POPULATION AND
PROBLEM
Current indications for leaving a patient’s abdomen
open are shown in Table 2. Decompression for
isolated ACS is an infrequent sole indication. Pivotal
moments in ACS history occurred when Fietsam
Department of Surgery, Letterkenny University Hospital, Donegal Clinical
Research Academy Ireland, Donegal, Ireland
Correspondence to Mr Michael Sugrue, MBBChBAOMD, FRCSI,
FRACS, Surgeon, Letterkenny University Hospital, Letterkenny, Kilma-
crennan Road, Ireland. E-mail: acstrauma@hotmail.com
Curr Opin Crit Care 2017, 23:73–78
DOI:10.1097/MCC.0000000000000371

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Special commentary
KEY POINTS
 Although excellence in care, early haemostasis and
control of sepsis will markedly reduce ACS, it will
never be abolished.
 Measurement of IAP and thoughtful decompression with
early closure will improve outcomes.
coined the term in 1989 [2], when the World
Society of the Abdominal Compartment Syndrome
(WSACS) defined IAH, its grades and the abdominal
compartment syndrome [1]. The clinical signifi-
cance of Grade 1 IAH remains a clinical issue. We
know that at a cellular level changes can occur even
with modest rises in IAP. The WSACS may have
achieved a greater universal acceptance if Grade 1
had been excluded. A direct causal relationship
between IAH and renal failure (independent of other
important confounders) was shown at pressures
of 15 and 18 mmHg in two large prospective series
over 20 years ago [3,4]. Despite its initial promise,
abdominal perfusion pressure (APP) has taken off
[5]. In part due to failure in ICU monitoring
equipment to include a recording channel for IAP
and secondly a pitfall of IAP monitoring – the lack
of a robust continuous real time IAP pressure
measurement system [6]. IAP should be measured
in all patients returning either to an ICU or High
Dependency Unit after an emergency laparotomy
or patients undergoing massive resuscitation
(>6 l in 24 h).
HOW TO DIAGNOSE ABDOMINAL
COMPARTMENT SYNDROME?
The World Society’s definition remains valid. It
requires however an IAP measurement and shame-
fully this is not routinely done in even high-risk
&
patients. Smit et al. [7 ] have recently emphasized
the importance of IAP measurement particularly in
pancreatitis. An IAP value can help trigger a clinical
intervention and early recognition of an underlying
Table 1. Current recommendations for grading IAH
IAH grading
Grade I 12–15 mmHg
Grade II 16–20 mmHg
Grade III 21–25 mmHg
Grade IV 25 mmHg
74 www.co-criticalcare.com
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Table 2. General indications for open abdomen (%)
General indications for open abdomen %
Damage control 40
Facilitate early second look 25
Multiple 20
Excessive contamination 10
Decompression to prevent treat ACS 5
ACS, abdominal compartment syndrome.
problem. Not only does IAP predict ACS but also
intra-abdominal sepsis.
ISSUES IN MEASURING INTRA-
ABDOMINAL PRESSURE
The WSACS recommends that IAP be measured
every 4–6 h in critically ill patients who demon-
strate risk factors for the development of IAH or ACS.
Once a nursing shift or 8 h is probably adequate.
Intermittent IAP is however somewhat artificial and
does not truly reflect the day-to-day activities of an
ICU patient. Clinical examination is not a reliable
measure of IAP and how often do you still see a tape
measure drawn on the abdomen [8] so we need an
objective simple reproducible way to measure IAP.
The gold standard for IAP measurement has been
the intravesical technique with instillation of 25 ml
physiological saline. A Foley manometer U tube
(Video 2 measuring IAP by the bedside with a man-
ometer, http://links.lww.com/COCC/A15) is most
widely used in Europe.
The failure to develop a robust simple continu-
ous IAP monitoring system is disappointing. Balogh
et al.’s [6] technique of using a three-way catheter,
while simple and inexpensive, requires a larger
three-way urinary catheter and therefore is not
practical, especially for male patients. IAP max
and changes in IAP (DIAP) need to be explored more
as a guide to patient abdominal compliance and
where they are on the pressure volume curve of
the abdomen [9].
WHEN TO DECOMPRESS?
Not always straightforward, but certainly it should
be decision before incision. Ivatury et al. [10]
was one of the first to advocate prophylactic decom-
pression. Prophylactic decompression should be
considered in patients with conditions shown in
Table 3.
Patients with intestinal ischaemia will benefit
by leaving the abdomen open, not only to facilitate
re-inspection and potential further resection but
Volume 23  Number 1  February 2017
 Abdominal compartment syndrome and the open abdomen Sugrue
Table 3. Indication for prophylactic decompression
Massively resuscitated trauma laparotomy patients
Unstable patients undergoing laparotomy for severe peritonitis
Mesenteric ischaemic with resected bowel
Abdominal wall loss
On double strength ionotropes
also to benefit from the benefits of negative pressure
wound therapy (NPWT). This particular subgroup
of patients does not need huge abdominal
incisions. The indication and frequency of use of
the open abdomen in nontrauma patients is less
well understood. Between 10 and 25% of trauma
patients undergoing abdominal surgery have had
open abdomens [11]. The reported incidence
in nontrauma general surgical patients is hard
&
to quantify [12,13,14 ,15]. In a recent review of
the open abdomen in 338 primary laparotomies
(excluding re-exploration of initial laparotomy) that
were performed in 1 year at Maryland, 96 patients
(28%) were managed with an open abdomen.
This probably reflects the tertiary referral pattern
to that hospital and a more realistic figure would
probably be 3–5% of nontrauma laparotomies
that need an open abdomen. The Maryland
series would be unusual and an open abdomen in
a general surgery patient would be the exception,
with rates of 2–5% of all laparotomies reflecting
usual practice. Recently Donegal Clinical Research
Academy, the World Society Emergency Surgery and
the rebranded Abdominal Compartment Society
suggested some key performance indicators relating
to ACS [16].
Harvin et al. [17] highlighted problems with
overuse of damage control patients. Damage
control laparotomy (DCL) was associated with an
18% increase in hospital mortality, a 13% increase
in ileus, a 7% increase in enteric suture line failure,
an 11% increase in fascial dehiscence and a 19%
increase in superficial surgical site infection.
Therefore, a cautious approach to open abdomen
is important. It is a life-saving procedure in the right
patient and a potential source of morbidity and
mortality in the wrong patient.
Atema et al. [15] in a recent review of open
abdomen in nontrauma patients identified 74 stud-
ies describing 78 patient series, comprising 4358
patients of which 3461 (79%) had peritonitis. The
mean age of the included patients ranged from 45 to
66 years, mean APACHE II scores ranged from 13 to
28 and mean Mannheim Peritonitis Index ranged
from 24 to 34 points.
Atema found that the overall mortality rate was
30.0% [95% confidence interval (CI) 27.1–33.0%].
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The lowest weighted mortality was seen in series
describing dynamic retention sutures (11.1%, 95%
CI 4.5–25.0%), whereas the highest mortality was
reported after loose packing (40.0%, 95% CI 25.5–
56.5%). When do you leave a peritonitic abdomen
open? Classically patients with Henschey III or IV
peritonitis do not need to have their abdomen left
open. The exception would be the unstable patient
on large doses of inotropes intra-operatively whom
the anaesthetic team are having difficulty maintain-
ing their blood pressure (BP).
Patients with pancreatitis need decompression if
they have pressure above 25 mmHg with increasing
abdominal signs and worsening respiratory status.
Smith recently highlighted the deleterious effect of
IAH in pancreatic patients. Mentula et al. [18] had
previously suggested that early decompression in
the right patient improves outcome in severe acute
pancreatitis. Failure to open (anterior abdominal
compartment) may result in failure to prevent
mesenteric ischaemia or delayed bowel resection
for gangrene. Before decompression one should
consider PC drainage of ascites if present and para-
lysis. Patients with high IAP and tissue oedema
&
may get intestinal ischaemia [7 ]. This ischaemia
is multifactorial but high pressure is a key factor.
Not all patients will have primary ACS and
increasingly we see secondary, tertiary or recurrent
ACS and finally in patients undergoing abdominal
wall reconstruction quaternary ACS [19]. Striking
a balance in fluid resuscitation has been very chal-
lenging and Mason et al. [20] from Sunnybrook
suggest that we may have gone too far and that
restrictive resuscitation predicted by the Parkland
Formula increases acute kidney injury without
increasing infectious complications. About 20% of
decompressed patients will develop tertiary ACS
from either persistent bleeding, sepsis or tissue
oedema. These patients need re-exploration unless
there is severe coagulopathy, which would need to
be addressed first if possible. These patients will
often benefit by a silo. Negative pressure therapy
will reduce tertiary abdominal compartment risk.
Tip-patients with tertiary ACS are more prone
to polycompartment syndrome, involving the
limbs [21].
WHAT IS THE BEST OPERATIVE
TECHNIQUE FOR LAPAROSTOMY?
Generally, small laparostomies are rarely indicated.
The exception to this is small bowel ischaemia,
wherein ideally when a preoperative diagnosis is
made, and following resection-revascularization
the open abdomen will facilitate a second look. This
is where trauma and general surgery differ somewhat,
www.co-criticalcare.com 75
Special commentary
FIGURE 1. Confounders to laparostomy closure include
ostomies.
with a smaller incision more acceptable in a general
surgical peritonitic patient.
Confounders to laparostomy closure include
ostomies, feeding jejunostomy and placement
of drains (Fig. 1). Drains are generally not needed
where an effective NPWT system is used. If an
anastomosis is performed in the presence of a lot
of tissue oedema then a handsewn technique, rather
than stapled, is preferable. If a stapled technique is
used, the stapler should be applied for 30 s before
firing and the anastomosis kept as far away from the
open abdomen as possible. In general, anastomosis
should be avoided in an open abdomen.
A lateral stoma should be considered to avoid
potential seal issues with NPWT dressing. Jejunos-
tomy should be avoided if possible as they may
leak due to the lack of adhesions from multiple
repeat operations. A transverse laparostomy, while
possible, does not give the same access.
MAINTAINING DOMAIN
Mesh-mediating traction system combined with
negative pressure is used from the first operation
(Video 3, mesh mediated traction with underlying
protective sheet being removed, http://links.
lww.com/COCC/A16) [22]. This is particularly
important where there is a lot of oedema and
massive resuscitation. It will help prevent lateraliza-
tion of the abdominal wall. The exception is in
resource challenged countries where realistically
NPWT may not be affordable. Frazee et al. [23] has
shown that commercial NPWT is cost effective.
Other techniques include trans-abdominal wall
traction (TAWT) [24]. While TAWT is effective
one needs to avoid maceration of the skin. Coloni-
zation of wounds is very common and increases
with the length of time the abdomen is left open.
NPWT offers improved outcomes [25,26]. Particular
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attention to sterility is important when patients
have an aortic graft or retroperitoneal necrosis.
WHEN DO YOU CLOSE?
You close EARLY. At the index operation for the
open abdomen the closure plan should be 24 h for
post ischaemia resection, 48 post trauma packing
and 7 days for pancreatitis. However, up to 15%
need re-exploring either due to tertiary, quaternary
ACS or wound dehiscence. At re-exploration, the
abdomen needs to be washed out with sequential
tightening of the mesh. Obtaining closure involves a
team approach involving ICU, nursing, medical and
theatre staff with active involvement from the sur-
gical consultant. Miller et al. [11] in a large series
identified that if the abdomen was not closed within
7 days the complication rate increased dramatically.
In Atema’s review, when NPWT was used without
fascial traction, a fistula rate of 14.6% was seen.
But when NPWT was combined with continuous
suture or mesh-mediated fascial traction fistula risk
dropped to 5.7%. There will be a number of patients
that you will not be able to close and you have not
closed by day 10; you will need to apply additional
cover. A biological mesh is probably preferable. It
remains to be seen the utility of those biological
meshes combined with non re-absorbable material.
Other options include skin coverage, which gener-
ally will require a releasing incision or a skin graft.
The advantage of grafting is that it will correct the
catabolic effect of the open abdomen quickly but
will doom the patient to a delayed ventral hernia
repair. A biological bridging mesh is probably most
suitable. Although Cothren’s group reported up to a
100% fascial closure, recent large series from
Germany of 355 patients even when Lambertz strati-
fied the data by years, patients operated in the last
2 years examined (2011–2013) still only reported a
fascial closure rate of 49% [27,28]. To facilitate
closure, a number of novel techniques had been
proposed. One of the most promising currently is
peritoneal resuscitation with hyperosmolar renal
dialysis fluid. Don’t ask for this in the middle
of your operation as there are over 30 different
bags of dialysis fluid – avoid the embarrassment,
plan ahead! Hypertonic saline intravenously has
been used to increase the fascial closure [17]. When
closing nearly 15% will dehisce so consideration of a
supplemental prophylactic on lay mesh or even the
old fashioned retention sutures. The skin should not
be left open unless there is significant contami-
nation. Although there will invariably be contami-
nation, overt infection is rare due mainly to effective
NPWT, and this will allow a subcuticular stitch.
The wound appearance and complication rate will
Volume 23  Number 1  February 2017
 Abdominal compartment syndrome and the open abdomen Sugrue
Table 4. Proposed key performance indicators for
abdominal compartment syndrome
Measurement of IAP post emergency laparotomy patients
ICU patients with either Grade 3 or 4 intra-abdominal
hypertension (IAH) (Grade 3: IAP 21–25 mmHg, Grade IV:
IAP > 25 mmHg) have evidence of ACS preventive strategy
Documented closure plan in operation sheet of index open
abdomen operation
Hospitals entero-atmospheric fistulae rate <10%
Use of NPWT abdominal dressing in open abdomen patient
ACS, abdominal compartment syndrome; IAP, intra-abdominal pressure;
NPWT, negative pressure wound therapy.
be reduced by the application of a closed incision
negative pressure therapy system.
A key to avoiding fistulae formation is to have
the abdomen closed. Generally, abdominal wall
closure will have to be delayed where there is a
fistula. Skin closure can be with subcuticular stitch.
This is despite existing colonization. If there is some
purulent material in the wound, loose interrupted
sutures can be used. If there is frank pus, a negative
pressure superficial wound system will facilitate
management and skin edges will heal by secondary
intention.
CONCLUSION
ACS can be prevented in most patients through
careful excellent hands on clinical care. Early con-
trol of haemorrhage particularly in conditions
such as major pelvic trauma, reduced the need for
massive transfusion. Avoiding massive crystalloid
resuscitation will reduce the incidence of ACS. This
in turn will prevent both primary and secondary
ACS. Opening an abdomen remains an important
tool in preventing ACS and should be accompanied
by a clear closure plan and de-resuscitation protocol.
IAP must be measured regularly in such patients.
Despite the amazing work and guidelines pro-
duced by WSACS and other Societies there remains a
great opportunity to improve outcomes further. In
July 2016, the Donegal Summit on Resource in
Emergency Surgery advocated new key performance
indicators to be measured in emergency surgery
(Table 4). The establishment of international
registries will help guide future care [29]. Novel
techniques such as peritoneal resuscitation need
to be explored [30]. To move forward we must not
forget the past, and realize that uncorrected high
IAP and associated IAH progresses to ACS and kills
patients. Prevention is crucial though excellent
management in early haemorrhage control and
clearance of sepsis.
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Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
M.S. has acted as a consultant to Smith and Nephew. He
has a number of patents relating to IAP measurement
and has no active commercial interest in them.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Malbrain M, Cheatham M, Kirkpatrick A, et al. Results from the International
Conference of Experts on Intra-abdominal Hypertension and Abdominal
Compartment Syndrome. I. Definitions. Intensive Care Med 2006;
32:1722–1732.
2. Fietsam R, Villalba M, Glover J, et al. Intra-abdominal compartment syndrome
as a complication of ruptured abdominal aortic aneurysm repair. Am Surg
1989; 55:396–402.
3. Sugrue M, Jones F, Deane S, et al. Intra-abdominal hypertension is an
independent cause of postoperative renal impairment. Arch Surg 1999;
134:1082–1105.
4. Sugrue M, Buist M, Hourihan F, et al. Prospective study of intra-abdominal
hypertension and renal function after laparotomy. Br J Surg 1995; 82:235–
238.
5. Cheatham M, White M, Sagraves S, et al. Abdominal perfusion pressure: a
superior parameter in assessment of intra-abdominal hypertension. J Trauma
2000; 49:621–627.
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measurement technique. Am J Surg 2004; 188:679–684.
7. Smit M, Buddingh K, Bosma B, et al. Abdominal compartment syndrome and
& intra-abdominal ischemia in patients with severe acute pancreatitis. World J
Surg 2016; 40:1454–1461.
This recent study confirms that ACS is common in severe acute pancreatitis.
Intra-abdominal ischemia occurs in a large proportion of patients with ACS.
Swift surgical intervention may be indicated when conservative measures fail in
patients with ACS. Especially when there was a high incidence of ACS in those
who have had IAP measured. ACS developed in 13/29 (44.8%) patients.
Ten patients with ACS underwent decompressive laparotomy. A large
proportion of patients with ACS had intra-abdominal ischemia upon laparot-
omy: 8/13 (61.5%). On note, IAP was only measured in half of the patients.
This is surprising from a country that has been a world leader in pancreatitis
research
8. Sugrue M, Bauman A, Jones F, et al. Clinical examination is an inaccurate
predictor of intraabdominal pressure. World J Surg 2002; 26:1428–1431.
9. Sturini E, Saporito A, Sugrue M, et al. Respiratory variation of intra-abdominal
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&
Interesting article on tertiary care of peritonitis many refer to a centre dealing with
end-stage patients. A total of 338 laparotomies were performed, of which 96
(28%) were managed with an open abdomen. A high mortality in this group is not
expected. Interesting to see a 10% fascial dehiscence again showing the complex-
ity we face.
www.co-criticalcare.com 77
Special commentary
15. Atema J, Gans S, Boermeester M. Systematic review and meta-analysis of the
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kidney injury are increased in patients who receive resuscitation volumes
less than predicted by the Parkland equation. Ann Surg 2016; 264:
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21. Malbrain MLNG, De laet I. A new concept: the polycompartment syndrome –
Part 2. Int J Intensive Care 2009; Spring:19–25.
22. Petersson U, Acosta S, Bjorck M. Vacuum-assisted wound closure and mesh-
mediated fascial traction – a novel technique for late closure of the open
abdomen. World J Surg 2007; 31:2133–2137.
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23. Frazee RC, Abernathy SW, Jupiter DC, et al. Are commercial negative
pressure systems worth the cost in open abdomen management? J Am Coll
Surg 2013; 216:730–735.
24. Denis AJ, Salabat R, Kingsley S, et al. Trans-abdominal wall traction as a
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Volume 23  Number 1  February 2017