When the Abdomen Cannot Be Closed: From Open Abdomen and Enteroatmospheric Fistula to Definitive Abdominal Wall Reconstruction

The open abdomen can be a life-saving intervention in selected patients with abdominal compartment syndrome, major trauma, severe intra-abdominal sepsis, or a continuing need for re-exploration.It also initiates a complex reconstructive pathway in which fascial retraction, visceral fixation, intestinal failure, and enteroatmospheric fistula may compromise eventual recovery.This narrative review integrates initial open-abdomen management, fistula control, intestinal rehabilitation, and definitive abdominal wall reconstruction, with particular attention to the applicability and limitations of the evidence at each transition.Early priorities are protection of exposed viscera and pursuit of safe primary fascial closure once resuscitation, source control, and bowel viability permit.Negative-pressure wound therapy with a fascial traction system may improve closure in selected patients, but the recommendation is conditional and rests largely on low-certainty observational evidence.When enteroatmospheric fistula develops, treatment centers on sepsis control, separation of enteric effluent from the wound, replacement of measured losses, and individualized nutritional support.Definitive intestinal surgery should be timed to clinical and biological readiness rather than a universal minimum interval.Simultaneous fistula takedown and abdominal wall reconstruction is feasible in selected patients but carries substantial wound morbidity and recurrence; staged treatment remains appropriate when contamination, tissue quality, or physiological reserve is unfavorable.Reconstruction prioritizes restoration of fascial continuity, protected mesh reinforcement when appropriate, and reliable soft-tissue coverage.Randomized evidence, including longterm follow-up, favors permanent synthetic over biologic mesh in selected clean-contaminated and contaminated ventral hernia repairs, but does not establish safety in an actively septic open abdomen with uncontrolled enteric leakage.The principal contribution of this review is a connected, evidence-calibrated pathway that distinguishes direct open-abdomen and fistula evidence from extrapolation and emphasizes intestinal autonomy, abdominal wall function, and patient experience alongside anatomical closure.