Key concepts in management of the open abdomen for infection source control

Intra-abdominal infection management consists of infectious source control, antimicrobial therapy and early hemodynamic support. Sometimes more than one laparotomy is needed to achieve source control. On-demand re-laparotomy is performed in severe septic patients, but there is no evidence of well-defined conditions that can lead to this therapeutic option.

Dr. Sartelli speaks about planned versus on-demand re-laparotomy.

Open abdomen (OA) is the simplest method to perform a planned re-laparotomy. After 10 years since the first publication on open abdomen, there is still no definitive data regarding its use in severe peritonitis.

The rationale for damage control surgery in patients with abdominal septic shock is the same as for trauma patients. After source control, resuscitation is optimized in the ICU. No prospective studies have been done for damage control surgery in non-trauma patients. The cytokine cascade can be controlled by OA, preventing the abdominal compartment syndrome, but little evidence exists to support its use. OA can also allow to perform definitive surgery with primary anastomosis.

Early fascial closure should be accomplished, with or without negative pressure therapy, following temporary abdominal closure. Negative pressure with continuous fascial traction might have better results regarding fascial closure, mortality and enteroatmospheric fistula.

Non-mesh and mesh-mediated closure techniques can be used for definitive closure.

Planned re-laparotomy is not recommended in patients with severe secondary peritonitis, according to the evidence. Damage control surgery may be an option in selected significantly physiologically deranged patients, but there is no evidence to make it a general strategy. Prolonged negative pressure may increase the risk of enteroatmospheric fistula.

The results of the trial on Closed or Open after Laparotomy for source Control in Severe Complicated Intra-abdominal sepsis (COOL Trial) should answer the question of whether OA is indicated for Intra-abdominal sepsis.