ORIGINAL ARTICLE

Treatment of the open

abdomen with topical
negative pressure therapy: a
retrospective study of
46 cases
Aleidis Caro, Carles Olona, Andrea Jiménez, Jordi Vadillo, Francesc Feliu,
Vicente Vicente

Caro A, Olona C, Jiménez A, Vadillo J, Feliu F, Vicente V. Treatment of the open abdomen with topical negative
pressure therapy: a retrospective study of 46 cases. Int Wound J 2011; 8:274–279

ABSTRACT
The open abdomen is an ongoing challenge for professionals engaged in its treatment. The change in the integrity
of the abdominal wall, the loss of fluids, heat and proteins and contamination of the wound are the main problems.
The objective of this article is to describe our experience using the abdominal dressing vacuum-assisted closure
therapy in treatment of the open abdomen. Since December 2006, all patients requiring treatment with the open
abdomen technique have been treated with the abdominal dressing system and vacuum-assisted closure therapy
(VAC® KCI, San Antonio, USA). The results obtained with this technique in non traumatic patients are analysed
herein. The abdominal dressing system was used on 46 patients in the period between January 2006 and December
2009, with a mean 63 years old (29–80), with a gender distribution of 33 men (72%) and 13 women (28%).
Closure of the abdominal wall was possible in 24 patients, 5 of which were primary in the recent postoperative
phase, 5 had primary suture of the fascia and application of the supra-aponeurotic prosthesis and 14 had closure
of the abdominal wall with a composite polytetrafluoroethylene (PTFE) and polypropylene mesh. Second intention
closure took place in the remaining 22 patients (48%), as their conditions did not allow primary closure. The mean
treatment time with abdominal dressing was 26 days (6–92) with an average of eight changes per patient. The
abdominal dressing topical negative pressure system is a useful option for consideration in the event of needing
to leaves the abdomen open. It stabilises the abdominal wall and quantifies and collects exudate from the wound,
protects the intra-abdominal viscera and keeps the fascia intact and the cutaneous plane for subsequent closure of
the wall.
Key words: Abdominal wound • Open abdomen • Topical negative pressure therapy

Authors: A Caro, MD, General Digestive Surgery Department, University Hospital Joan XXIII de Tarragona, Rovira i Virgili University,
43007 Tarragona, Spain; C Olona, PhD, General Digestive Surgery Department, University Hospital Joan XXIII de Tarragona, Rovira i Virgili
University, 43007 Tarragona, Spain; A Jiménez, MD, General Digestive Surgery Department, University Hospital Joan XXIII de Tarragona,
Rovira i Virgili University, 43007 Tarragona, Spain; J Vadillo, MD, General Digestive Surgery Department, University Hospital Joan XXIII
de Tarragona, Rovira i Virgili University, 43007 Tarragona, Spain; F Feliu, PhD, General Digestive Surgery Department, University Hospital
Joan XXIII de Tarragona, Rovira i Virgili University, 43007 Tarragona, Spain; V Vicente, PhD, General Digestive Surgery Department,
University Hospital Joan XXIII de Tarragona, Rovira i Virgili University, 43007 Tarragona, Spain
Address for correspondence: A Caro, MD, General Digestive Surgery Department, University Hospital Joan XXIII de Tarragona,
Rovira i Virgili University, 43007 Tarragona, Spain
E-mail: dra5028@gmail.com

© 2011 The Authors

274 © 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 8No 3

INTRODUCTION
The open abdomen is an ongoing challenge
for professionals engaged in its treatment. The
change in the integrity of the abdominal wall,
the loss of fluids, heat and proteins and contam-
ination of the wound are the main problems.
Various mechanisms have been used to date
in treatment of the open abdomen, including
the Bogota bag, the Sandwich Vacuum Pack
and the Witmann Patch system. The advantage
of the topical negative pressure system is its
direct and active effect on the fascia, encourag-
ing the growth of the granulation tissue and
facilitating primary closure (1). This system
requires less nursing treatment and enables
early mobility of the patients.
The vacuum-assisted closure therapy abdo-
minal dressing stabilises the abdominal wall by
transmiting uniform mechanical forces to the
surrounding tissue without creating tension at
wound level, controls fluid loss at the same
time as eliminating exudate, reduces retrac-
tion of the fascia and cutaneous necrosis and
protects the intra-abdominal viscera (2).
Since 2006, we have used topical negative
pressure therapy to treat the open abdomen.
The objective of this article is to describe
our experience using the abdominal dressing
vacuum-assisted closure therapy to treat the
open abdomen.
MATERIALS AND METHODS
Since December 2006, all patients requiring
treatment with the open abdomen technique
have been treated with the abdominal dressing
system and vacuum-assisted closure therapy
(VAC® KCI, San Antonio, USA). The results
obtained with this technique in non traumatic
patients are analysed herein.
The classification system devised for open
abdominal wounds was used to classify
patients. Those considered to require open
abdomen treatment were patients with abdom-
inal wounds of grade II (intestine or omentum
exposed) and grade III (intra-abdominal sep-
sis) and those with an anticipated risk of high
intra-abdominal pressure that can cause post-
operative abdominal compartment syndrome:
that is to say, patients who present intestinal
oedema or difficulty in closing the abdominal
wall (2).
The dressing is applied for the first
time in the operating theatre, under general
© 2011 The Authors
© 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Open Abdomen
Key Points
• the open abdomen is an ongo-
ing challenge for professionals
engaged in its treatment
• the advantage of the topical
negative pressure system is its
direct and active effect on the
fascia, encouraging the growth
of the granulation tissue and
facilitating primary closure
• this system requires less nursing
Figure 1. The abdominal dressing system. treatment and enables early
mobility of the patients
anaesthetic, at the end of the surgical operation • the objective of this article
creating the problem for primary closure. The is to describe our experience
using the abdominal dressing
subsequent changes are made in the operat- vacuum-assisted closure ther-
ing theatre or the intensive care unit under apy to treat the open abdomen
sedation. • since December 2006, all
The abdominal dressing pack consists of: an patients requiring treatment
abdominal visceral protection dressing with a with the open abdomen tech-
nique have been treated with
piece of non adherent perforated laminated the abdominal dressing sys-
polyurethane foam, two pieces of perforated tem and vacuum-assisted clo-
polyurethane foam enabling correct distribu- sure therapy (VAC® KCI, San
tion of the negative pressure throughout the Antonio, USA)
open abdomen and a semi-occlusive sheet to • the results obtained with this
technique in non traumatic
seal the area where the abdominal dressing patients are analysed herein
subsidiary to the VAC® therapy has been
placed (Figure 1). In the event of an intestinal
fistula appearing, VAC® WhiteFoam dress-
ings, consisting of a polyvinyl alcohol dressing
designed for handling difficult wounds and
intestinal fistulas were used.
The procedure followed in all the patients
treated with the VAC® abdominal dressing
system was as follows:
1. The VAC® abdominal dressing system
was applied directly in contact with
the exposed intestinal fluids intraperi-
toneally, and the sheet spread intra-
abdominally in the correct manner. This
visceral protection layer protects the
intestines from direct contact with the
polyurethane foam.
2. After application of the abdominal dress-
ing, the perforated polyurethane foam
piece was applied, with one or two lay-
ers used depending on the size of the
problem in the abdominal wall. The per-
forated foam dressing must be adjusted
to the wound to achieve the correct
contraction of the wound and approxi-
mation to its edges. This dressing must
not be placed directly over the exposed
intestine.
275
 Open Abdomen
Key Points
• the abdominal dressing system
was used on 46 patients in the
period between January 2006
and December 2009, with a
mean 63 years old (29–80),
with a gender distribution of
33 men (72%) and 13 women
(28%)
• closure of the abdominal wall
was possible in 24 patients, 5
of which were primary in the
recent postoperative phase, 5
had primary suture of the fascia
and application of the supra-
aponeurotic prosthesis and 14
had closure of the abdominal
wall with a composite PTFE and
polypropylene mesh
• second intention closure took
place in the remaining 22
patients (48%), as conditions
did not allow primary closure
abdominal wound, the appearance and spread
of the granulation tissue, the quality of the
aponeurotic and cutaneous tissues and the
patient’s general conditions, the final abdom-
inal closure and type of closure will be deter-
mined by assessing the following factors:
276
3. The polyurethane pieces were then fixed
with semi-occlusive adhesive drapes,
which adjust to their size, leaving an
excess edge of 2–5 cm. The skin around
the wound must be completely clean
and dry for correct fixation. If stoma is
present, it must be isolated by cutting the
surrounding drape.
4. Finally, an opening is cut in the adhesive
drape of around 2–3 cm diameter and
the TRACpad is placed on this opening.
The TRACpad is then connected to the
Therapy Unit and the negative pressure
to be applied to the wound regulated.
In our patients, this pressure ranged
between −100 and −125 mmHg applied
continuously.
5. In the subsequent changes of therapy, the
procedure set out for the first application
was followed, but the abdominal cavity
was cleaned using physiological serum
before applying the abdominal dressing.
If the size of the abdominal wound
decreased, the abdominal dressing layer
was trimmed to prevent the edges from
become creased or rolled up.
6. If intestinal fistulae occur while using
VAC® therapy with abdominal dressing,
they can be excluded by applying a
VAC® WhiteFoam dressing, and the
intensity and continuity of the negative
pressure applied to the wound is reduced
(−50 mmHg intermittently).
Depending on the size and type of the
1. If the aponeurotic quality is good, with
no risk of an increase in intra-abdominal
pressure, the choice is primary closure
with or without a supraponeurotic mesh.
2. In cases in which diastasis of the aponeu-
rotic edges made this approach impossi-
ble, we used a composite prosthesis of
PTFE and polypropylene and assisted
final closure with a suprafascial VAC
system.
3. For those patients for whom primary
closure is not possible because of their
general ill health or the bad condition
of the wound, treatment with the
abdominal dressing was maintained until
the formation of granulation tissue which
completely healed the abdominal wall,
leaving a residual eventration which will
subsequently be resolved as the patient’s
general conditions improve.
RESULTS
The abdominal dressing system was used on
46 patients in the period between January
2006 and December 2009, with a mean 63 years
old (29–80), with a gender distribution of
33 men (72%) and 13 women (28%).
The diagnoses requiring vacuum-assisted
closure were 9 cases of abdominal compart-
ment syndrome, 22 cases of secondary peritoni-
tis, 4 pancreatostomies because of acute com-
plicated pancreatitis, 5 mesenteric ischemias,
3 abdominal aneurysm ruptures and 3 evis-
cerations because of infection of the surgical
wound (Table 1). A supra-infraumbilical mid-
line laparotomy was performed in all cases
except in the three abdominal aneurysm rup-
tures, which were treated with a bilateral
subcostal laparotomy.
Closure of the abdominal wall was possible
in 24 patients, 5 of which were primary in
the recent postoperative phase, 5 had primary
suture of the fascia and application of the
supra-aponeurotic prosthesis and 14 had
closure of the abdominal wall with a composite
PTFE and polypropylene mesh. Closure with
prosthesis takes place when the conditions
of the patient and abdominal wall make this
possible, and in these cases it was on around
the tenth day of therapy.
Second intention closure took place in the
remaining 22 patients (48%), as conditions did
Table 1 Distribution of diagnoses
Diagnosis
Compartment syndrome 9
Peritonitis 2nd anastomotic dehiscence 3
Peritonitis 2nd perforation empty viscera 13
Peritonitis 2nd diverticulitis 4
Postoperative abcess 2
Pancreatectomy 4
Mesenteric ischemia 5
Aortic aneurysm rupture 3
Wound infection and evisceration 3
Total 46
© 2011 The Authors
© 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc

Figure 2. Enteric fistula in a patient treated with the
abdominal dressing system.
not allow primary closure. In six cases, this was
because of the appearance of an enteric fistula
and in the remaining 16 because of comorbidi-
ties (Figure 2). These patients presented evis-
ceration secondary to second intention closure
and were monitored in the outpatients’ clinic.
When they had recovered their general health,
the evisceration was treated by Chevrel repair.
Two cases were observed of intestinal anas-
tomotic dehiscence requiring further surgery,
intestinal suture and continuation of the clo-
sure with abdominal dressing. Eight enteric
fistulas also appeared (17%). When these com-
plications arise, the treatment is complex. In
one case, exclusion by an ileostomy and a
mucus fistula was possible. In two cases,
they were excluded using VAC® WhiteFoam
dressing and protected with a Foley catheter
until improvement in the tissues enabled the
resection of the affected loop and enteric anas-
tomosis. In the other five cases, the same
treatment was used but without a catheter and
WhiteFoam, but the patients presented deteri-
oration because of the basic pathologies that
led to their death before it was possible to
undertake the final treatment of the fistula.
The mean treatment time with abdominal
dressing was 26 days (6–92) with an average
of eight changes per patient. We observed no
mortality caused directly by the abdominal
dressing mechanism, but total mortality was
32.6%, or 15 patients, due to the septic profile
presented with their basic pathology.
DISCUSSION
There are five recognised indications for leav-
ing the abdomen open, which are severe intra-
abdominal infection, acute mesenteric ischemia
© 2011 The Authors
© 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Open Abdomen
in order to be able to take a second look, necro-
tizing infection of the abdominal wall, damage
control surgery in traumatic patients and cases
of intra-abdominal hypertension (3,4).
There are various options if the abdomen
needs to be left open, such as the Bogota Bag
or the Witmann Patch. In 1995, Brock et al.
and Barker described the Sandwich Vaccum
Pack technique in which a polyethylene layer
acts as a physical barrier between the viscera
and the abdominal wall, preventing adherence
between the intestine and the wall (5,6).
VAC® with abdominal dressing therapy
stabilises the abdominal wall and improves
respiratory function in patients, quantifies
and drains exudate from the wound and
reduces contamination by creating an interface
between the abdominal cavity and the exte-
rior. As Argenta reported, the negative pres-
sure applied to the Foam transmits uniform
mechanical forces to the edges of the wound,
which prevents the fascia from retracting (1,7).
One of the main advantages of the therapy
is that it speeds up the healing process and
enables early movement of the patient by
reducing the frequency of treatment to every
48 hours, which has a positive effect on the
patient’s psychophysical state. It also enables
the abdominal cavity to be checked and washed
during each treatment if necessary (2,8).
The European Wound Management Associa-
tion has published a series of measures forming
a protocol for the use of VAC® therapy (7).
In general, patients requiring treatment with
abdominal dressing topical negative therapy
are usually complex patients, in a critical state
and not very homogenous, which prevents
randomised studies showing the advantages
of the therapy (9).
Despite this method being useful for the
treatment of the open abdomen, the technique
is not free of complications. Of these, the most
common and complex to treat is the abdominal
fistula. There is no evidence that the appear-
ance of enteric fistulas is a consequence of the
use of VAC® therapy as these are very complex
wounds (generally type IIIA) (9). Possible risk
factors for enteric fistula are prior multi-organ
failure, abdominal sepsis, the presence of pros-
thesis material or enteric suture and the sever-
ity of the abdominal wound (10–14). There is
no clear scientific evidence to suggest that the
negative pressure applied to the open abdomen
wound is directly related to the appearance of
Key Points
• there are five recognised indica-
tions for leaving the abdomen
open, which are severe intra
abdominal infection, acute
mesenteric ischemia in order
to be able to take a second
look, necrotizing infection of the
abdominal wall, damage con-
trol surgery in traumatic patients
and cases of intra-abdominal
hypertension
• VAC with abdominal dressing
therapy stabilizes the abdomi-
nal wall and improves respira-
tory function in patients, quan-
tifies and drains exudate from
the wound and reduces contam-
ination by creating an interface
between the abdominal cavity
and the exterior
• one of the main advantages of
the therapy is that it speeds up
the healing process and enables
early movement of the patient
by reducing the frequency of
treatment to every 48 hours,
which has a positive effect
on the patient’s psychophysical
state
• patients requiring treatment
with abdominal dressing topi-
cal negative therapy are usu-
ally complex patients, in a
critical state and not very
homogenous, which prevents
randomised studies showing the
advantages of the therapy
• there is no clear scientific
evidence to suggest that the
negative pressure applied to the
open abdomen wound is directly
related to the appearance of
enteric fistulae
277

Key Points
• the cost-benefit economic man-
agement of the therapy remains
uncertain as this type of patient
is very complex, and require
long stays in hospital and in
intensive care units
• in our case, it was not possible
to undertake a costs study
although using this therapy did
enable us to care for the patients
in their beds either in the
intensive care unit or in the
ward, with no need to move and
occupy an operating theatre
• the abdominal dressing topical
negative pressure system is a
useful option for consideration
in the event of needing to leaves
the abdomen open
• it stabilizes the abdominal wall
and quantifies and collects exu-
date from the wound, protects
the intra-abdominal viscera and
keeps the fascia intact and the
cutaneous plane for subsequent
closure of the wall
• this system fosters the healing
of the wound and optimises
nursing care, providing greater
autonomy for the patient and
leading to earlier mobility
• the most frequent and diffi-
cult to treat complications are
enteric fistulas
• VAC therapy enables the
fistula to be excluded and
reduces contamination of the
wound
• the cost-benefit this of system
needs to be analysed with ran-
domised studies that enable it
to be compared with other open
abdomen treatment techniques
278
Open Abdomen
enteric fistulae. Even so, we believe that the
habitual negative pressure used (between −100
and −125 mmHg) may contribute to the devel-
opment of such fistulae. For this reason, in
patients who present an enteric fistulae we use
an intermittent negative pressure that is lower
than normal (−50 mmHg). Some authors rec-
ommend lowering the aspiration pressure in
the therapy by half to prevent these fistulae
from appearing (15). Up to 66% of enteric fis-
tulas were described in this type of treatment
although in our series, which presents a sub-
stantial n, this complication was only observed
in 17% of cases (16–19). VAC® therapy enables
exclusion of the fistula, while isolating the rest
of the wound, preventing its contamination
by aspiration of the fistula output. The usual
choice is a deferred repair of the enteric fis-
tula when the patient’s baseline and nutritional
state is optimum, and in our series this was
possible in three out of the eight cases.
VAC® therapy maintains both the fascia and
the cutaneous plane intact and as such facili-
tates their primary deferred closure, associated
or otherwise with the application of a proth-
esic mesh (20). However, the ideal situation
of being able to close the abdominal wall at
an early stage occurs on very few occasions
as the critical state of the patient prevents this.
Even so, in accordance with the observations of
Estas Bovill, the continuity of treating the open
abdomen with VAC® therapy is believed to be
beneficial for patients in a critical state because
it improves their general condition (2). This
increases the risk of the appearance of compli-
cations such as enteric fistulas which delay the
closure of the abdominal wall even further, as
occurred in some patients in our series (21).
The cost-benefit economic management of
the therapy remains uncertain as this type of
patient is very complex, and require long stays
in hospital and in intensive care units. Some
studies have shown the economic advantages
of this therapy as it saves nursing time and care
material and shortens the stay in hospital, but
randomised comparative studies are necessary
to assess its overall cost (15,21,22). In our case,
it was not possible to undertake a costs study
although using this therapy did enable us to
care for the patients in their beds either in
the intensive care unit or in the ward, with
no need to move and occupy an operating
theatre.
CONCLUSIONS
The abdominal dressing topical negative pres-
sure system is a useful option for consideration
in the event of needing to leaves the abdomen
open. It stabilises the abdominal wall and quan-
tifies and collects exudate from the wound,
protects the intra-abdominal viscera and keeps
the fascia intact and the cutaneous plane for
subsequent closure of the wall.
This system fosters the healing of the wound
and optimises nursing care, providing greater
autonomy for the patient and leading to earlier
mobility.
The most frequent and difficult to treat com-
plications are enteric fistulas. VAC® therapy
enables the fistula to be excluded and reduces
contamination of the wound.
The cost-benefit of this system needs to be
analysed with randomised studies that
enable it to be compared with other open
abdomen treatment techniques.
ACKNOWLEDGEMENTS
This study has not received any form of
funding.
We are grateful to the Language Service of
the Rovira i Virgili University for translating
the original text.
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