editorial Scandinavian Journal of Surgery 97: 218–219, 2008

the hostile abdomen – a systematic approach

to a complex problem

Hostile abdomen refers to a situation where the abdominal cavity is open and scarred into a one solid mass
with fragile small bowel loops adhered to each other, often complicated with enterocutaneous or “entero-
atmospheric” fistulae and retraction of the abdominal wall edges – a surgical nightmare. It can be the end
result of secondary peritonitis, severe acute pancreatitis, anastomotic leakage with multiple reoperations,
staged management of abdominal trauma (damage control surgery), or with increasing frequency the result
of open abdomen techniques following decompressive laparostomy for abdominal compartment syndrome
(1, 2). Most of these patients end up in the Intensive Care Unit with multiple organ dysfunctions and complex,
multiresistant infections looked after by more than one specialists including the intensivists, surgeons and
infection specialists.
Like for any complex problem, there are no easy solutions to a hostile abdomen. However, while the
treatment often has to be individualized, it is possible to bring order to the chaos by attempting a systematic
approach utilizing the expertise of multiple specialists. The key issues are in the order of things, timing and
coordination, not trying to do all at one go, and a need for a definitive plan with set intermediate goals (3).
The first priority is to control the infection source and treat the systemic effects of sepsis when present.
Source control can sometimes be achieved with intestinal repair or diversion, but often the only option avail-
able is to control the enteric leak with external drainage using multiple drains of sufficient diameter and
decompressing the involved bowel segment, especially the duodenum with multiple intraluminal tubes in-
cluding a T-tube in the common bile duct. While it is tempting to remove the external drains as soon as pos-
sible, the time-honoured technique of gradual shortening of the drains until a controlled fistula tract is formed
is often the safest way.
The second priority involves creating favourable local and systemic conditions for healing and consist of
organ and nutritional support with preferably enteral route of feeding, antimicrobial treatment and managing
the open abdomen utilizing modern vacuum-based dressing techniques (4).
When further abdominal explorations to control the source of infection are deemed unlikely, a plan for
definitive surgical treatment to restore gastroinintestinal continuity and correct the abdominal wall defect is
needed. If gradual primary fascial closure is impossible, the best option is to resort to the planned hernia ap-
proach and cover the bowel loops with split thickness skin grafts that often results in tuning down the inflam-
matory response induced by the “catabolic drain” of exposed viscera (5). If the enteric fistula is controlled at
this stage, attempts at early restoration of the continuity of the gastrointestinal tract are often futile and can
pose a grave risk to the patient. Patience is needed, both from the patient and the surgeon.
When the skin graft has matured which usually takes 6–12 months, and the patient is in good nutritional
condition, definitive repair of the gastrointestinal tract and the abdominal wall defect can be planned. They
can usually be performed in a single operation utilising the expertise of both gastroenterological and plastic
surgeons. While the restoration of the gastrointestinal continuity follows the established techniques of one or
multiple intestinal anastomoses, the method of the reconstruction of the abdominal wall defect needs to be
tailored individually. The most common techniques used include the components separation technique, use
of an artificial mesh prosthesis and an autologous tissue with pedicular or microvascular flaps (6). The most
commonly used is the tensor fascia lata -flap (7).
The management of a patient with a hostile abdomen requires profound knowledge of the treatment op-
tions, awareness of potential complications at any stage of the treatment, a systematic approach, involvement
of multiple specialties and patience. The best approach can be summarized with a quote attributed to Albert
Einstein: “Things should be made as simple as possible, but not any simpler.”

Key words: Open abdomen; surgical complications; enteric fistula; laparostomy; abdominal compartment
syndrome
 Editorial 219

REFERENCES
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tion. J Trauma 1999;46:519–522

Ari Leppäniemi
Editor-in-Chief