The open abdomen: definitions, management principles, and nutrition support considerations

The use of the "open abdomen" as a technique in the management of the complex surgical patient stems from the concept of damage control. Damage control principles underscore the importance of an abbreviated laparotomy focused on control of hemorrhage and gastrointestinal contamination in patients presenting with significant physiologic compromise. Definitive repair of injuries is postponed and the abdomen is temporarily "closed" using one of a number of different techniques. The ultimate goal is formal abdominal fascial closure within 48-72 hours of the initial laparotomy. Frequently, daily trips to the operating room are required for incremental closure of the abdominal fascia. However, in some cases, fascial closure is not possible secondary to ongoing visceral edema and loss of the peritoneal domain. In these cases, the patient is left with an "open abdomen" until skin grafting over the exposed peritoneal organs can be performed. Patients with an open abdomen have peritoneal contents exposed to the atmosphere and require a complex dressing to maintain fascial domain and provide protection to exposed organs. These patients are typically critically ill and managed in the intensive care unit early in the disease process. The open abdomen has become an important tool for the management of physiologically unstable patients requiring emergent abdominal surgical procedures. These patients present unique challenges to the critical care and nutrition support teams. Careful attention to fluid and electrolyte management, meticulous wound care, prevention of enteroatmospheric fistula, and individualized nutrition support therapy are essential to successful recovery in this patient population.