Contemporary management of the open abdomen: standards, challenges, and future directions

OBJECTIVE: The open abdomen (OA) is a key strategy in damage control surgery (DCS) for severe intra-abdominal pathology but is associated with considerable morbidity, including enteroatmospheric fistula (EAF) and failure of fascial closure. This narrative review summarizes current evidence on indications, temporary abdominal closure (TAC), timing of closure, and supportive care. METHODS: A structured PubMed/MEDLINE, Embase, Scopus, and Web of Science search was performed up to January 2025 in accordance with PRISMA principles. Relevant systematic reviews, meta-analyses, clinical guidelines, registry analyses, and prospective studies published in English were included. Given the narrative design, no meta-analysis was conducted. RESULTS: Negative pressure wound therapy (NPWT) combined with dynamic fascial traction represents a preferred TAC strategy, achieving primary closure rates up to 80-90% in selected patients. Early fascial closure (within 5-7 days) is associated with fewer complications, particularly EAF. Early enteral nutrition (24-48 h), when feasible, may support fascial approximation. However, available evidence is largely observational and heterogeneous, with substantial inter-institutional variability. CONCLUSION: Optimal OA management requires appropriate indication, standardized TAC strategies, and a proactive approach to early closure. When primary closure is not feasible, a planned ventral hernia remains a safe alternative. High-quality prospective studies are needed to strengthen the evidence base.