 Techniques and Systems](https://file-host.link/website/subq-it-sg5ksg/assets/blog-images/68d69f11-41b2-48c7-b4fe-9c9a71194f63/1771853827438477_566606d132a74d7c9cf47930edac176a/360.webp)
Introduction
A trauma surgeon stands over a patient after damage control laparotomy, facing a critical decision: the abdomen cannot be closed. The "triad of death"—hypothermia, acidosis, coagulopathy—demands abbreviated surgery, but leaving viscera exposed risks catastrophic complications.
This scenario drives the need for temporary abdominal closure (TAC), a technique that has become essential in modern trauma and acute care surgery. TAC prevents abdominal compartment syndrome while allowing for planned re-exploration—challenges that surgeons face daily when deciding between leaving the abdomen open versus risking premature closure.
Surgeons struggle with selecting the optimal TAC approach from multiple available techniques, each with distinct advantages for specific clinical scenarios. This article breaks down the core TAC systems—from negative pressure wound therapy to commercial devices—their clinical applications, and evidence-based selection criteria to help you choose the right method for your patients.
TL;DR
- TAC protects abdominal contents when immediate fascial closure is unsafe
- Five main techniques: NPWT, fascial traction, mesh closure, plastic silos, skin approximation
- Selection depends on injury severity, physiology, timeline, and compartment syndrome risk
- Early fascial closure within 5-7 days significantly improves outcomes
What Is Temporary Abdominal Closure?
Temporary Abdominal Closure (TAC) is a surgical strategy where the abdominal fascia is intentionally left open with protective coverage after laparotomy, allowing for physical recovery and planned re-exploration.
When TAC Is Indicated
Surgeons choose TAC when primary fascial closure would risk abdominal compartment syndrome (ACS), when the "triad of death" is present, or when serial washouts are anticipated.
Critical Physiologic Thresholds for TAC:
| Clinical Parameter | Threshold Value | Clinical Significance |
|---|---|---|
| Acidosis | pH < 7.2 or lactate ≥ 5 mmol/L | Indicates inadequate tissue perfusion |
| Hypothermia | Core temperature < 34°C | Impairs coagulation and cardiac function |
| Coagulopathy | INR/PT > 1.5 times normal | Increases bleeding risk |
| Intra-abdominal Pressure | IAP ≥ 25 mmHg | Risk of abdominal compartment syndrome |
These thresholds help surgical teams determine when immediate fascial closure could harm the patient more than leaving the abdomen temporarily open.
TAC vs. Definitive Closure
The distinction between temporary and definitive closure is critical for patient outcomes:
- Temporary closure: Protects viscera during the open abdomen phase while allowing access for re-exploration
- Definitive closure: Final fascial and skin closure performed once physiologic conditions normalize
- Timeline: TAC typically maintained for 24-72 hours, though duration varies based on patient response
Why Is Temporary Abdominal Closure Important in Trauma and Acute Care Surgery?
In critically injured patients, temporary abdominal closure (TAC) prevents abdominal compartment syndrome (ACS), a life-threatening condition where sustained intra-abdominal pressure (IAP) exceeding 20 mmHg causes cardiovascular collapse, respiratory failure, and renal injury.
ACS compresses the vena cava (decreasing cardiac output), elevates the diaphragm (impairing ventilation), and reduces renal perfusion through direct compression.
Core Benefits in Damage Control Surgery
TAC enables damage control surgery principles: abbreviated initial operation, physiologic resuscitation in the ICU, then planned return to the OR for definitive management.
This approach has contributed to improved survival rates in critically injured patients, with modern TAC systems associated with mortality rates as low as 15.7% in complex trauma cohorts.
These survival improvements depend on preventing serious complications that arise when TAC is inadequate or absent:
- Lateral migration of fascial edges causes loss of abdominal domain, making delayed closure impossible
- Enteroatmospheric fistulas occur in up to 25% of patients with prolonged open abdomen
- Complex ventral hernias develop in over 50% of patients at 5 years when primary closure fails
- Infection and sepsis risk increases significantly with prolonged open abdomen duration
Types of Temporary Abdominal Closure Techniques
TAC techniques have evolved from simple packing methods to sophisticated systems that protect viscera, manage fluid, and actively work toward fascial closure. Techniques differ in their mechanism (passive protection vs. active traction), invasiveness, resource requirements, and suitability for different clinical scenarios.
Negative Pressure Wound Therapy (NPWT/VAC Systems)
NPWT (Negative Pressure Wound Therapy) uses a foam or gauze interface over the viscera, covered by an occlusive dressing connected to controlled suction (typically -125 mmHg) to remove fluid and promote granulation tissue.
The system provides passive protection and fluid management but does NOT provide active fascial traction to prevent lateral retraction. NPWT actively removes peritoneal fluid and inflammatory cytokines, reduces visceral edema, and protects viscera from the external environment.
Best suited for:
- Patients requiring serial washouts
- Contaminated abdomens needing source control
- Those with significant fluid accumulation
Key strengths:
- Achieves primary fascial closure in approximately 50-70% of patients
- Widespread availability and familiarity among surgical teams
- Most widely adopted TAC technique (used by 94% of facilities in major trauma studies)
Limitations: Without fascial traction, lateral retraction increases and closure becomes progressively difficult after 7-10 days. NPWT alone does not prevent the natural lateral migration of fascial edges.
Clinical note: NPWT is often the base layer in combination approaches (NPWT + fascial traction) to maximize both fluid management and closure success.
Dynamic Fascial Traction Systems
These systems apply continuous or adjustable tension to fascial edges to prevent lateral retraction and progressively reduce the fascial gap. Options include the Wittmann Patch (Velcro-like sheets sutured to fascia), AbClo (non-invasive pressure-regulated device), and dynamic retention sutures (ABRA).
Invasive systems are sutured through fascia/abdominal wall, while non-invasive systems use external pressure regulation. Both maintain tension and prevent loss of domain.
Best suited for:
- Patients where early primary fascial closure is the goal
- Those with risk of significant fascial retraction
- When prolonged open abdomen is anticipated
Key strengths:
- Improve primary fascial closure rates to 80-98%
- Some systems allow bedside adjustments that reduce OR trips
- Wittmann Patch achieves 78-93% closure rates
- ABRA combined with NPWT: 100% closure vs. 28% for NPWT alone in trauma cohorts
Limitations:
- Invasive systems may cause tissue trauma at suture sites
- Require repeated OR visits for adjustment (mean 2.4 trips vs. 1.8 for non-invasive options)
- Higher cost compared to basic NPWT (though cost-effectiveness analyses suggest savings through reduced complications)
Biologic or Synthetic Mesh Closure
Surgeons sew mesh (biologic or synthetic) to fascial edges as an inlay or underlay bridge when primary fascial closure is not possible. The mesh serves as a scaffold for tissue ingrowth.
This approach provides structural support to contain viscera while allowing for planned ventral hernia repair at a later stage. Biologic mesh may be preferred in contaminated fields, though evidence for superiority is limited.
Best suited for:
- Patients where fascial edges cannot be approximated despite traction
- Anticipated loss of domain
- When transition to definitive closure will be significantly delayed
Key strengths:
- Allows abdominal domain preservation and visceral protection when other methods fail
- Can be combined with NPWT and skin grafting
Limitations:
- Bridging with mesh results in planned ventral hernia in nearly 100% of cases
- Requires subsequent complex abdominal wall reconstruction
- Biologic meshes cost up to 200 times more than synthetic options ($17,000 vs. $105)
- Recurrence rates reach 80% when used as a bridge
Plastic Silo (Bogotá Bag) Technique
The Bogotá Bag technique uses a sterile plastic sheet (often a 3-liter IV bag) sewn to the fascial or skin edges to create a temporary barrier over the viscera.
This low-cost, readily available method provides basic visceral protection but minimal fluid management and no fascial traction.
Best suited for:
- Resource-limited settings
- Emergent situations where commercial systems are unavailable
- Temporizing measure during initial resuscitation
Limitations:
- Higher rates of fluid loss, infection, and fascial retraction compared to NPWT-based systems
- Closure rates significantly lower than traction systems (54.9% vs. 73%)
- Largely replaced by NPWT in developed settings but remains valuable in resource-limited environments
Skin-Only Approximation and Towel Clip/Zipper Techniques
These techniques approximate skin edges without fascial closure, using towel clips, running sutures, or surgical zippers to provide temporary coverage.
The methods close the skin envelope while leaving fascia open, protecting viscera and reducing fluid loss but accepting that fascial closure will occur later or result in planned hernia.
Best suited for:
- Patients where fascial closure is clearly not achievable in the near term
- As adjunct to other techniques (e.g., skin approximation over mesh)
Limitations:
- High rates of abdominal compartment syndrome (13-36%), evisceration, and skin injury
- Accepts planned ventral hernia without actively working toward primary fascial closure
- Largely abandoned in modern practice due to complication rates
How to Choose the Right Temporary Abdominal Closure Technique
Selection should be based on patient physiology, injury pattern, available resources, and realistic timeline to definitive closure—not on surgeon preference alone.
Factor 1 - Patient Physiology and Stability
Unstable patients in the "triad of death" need the simplest, fastest TAC (NPWT ± plastic silo initially). Stable patients can undergo more complex traction systems that require additional OR time for placement.
Factor 2 - Contamination and Infection Risk
Heavily contaminated abdomens often respond best to NPWT alone initially, with transition to traction systems once source control occurs. If mesh is necessary in contaminated fields, prefer biologic mesh over synthetic, though cost considerations can be significant.
Factor 3 - Expected Timeline to Closure
Your closure timeline directly impacts technique selection.
- 3-5 days: NPWT may suffice
- 5-10 days: Add fascial traction to prevent retraction
- >10 days or closure unlikely: Consider mesh bridge early to preserve domain
Factor 4 - Available Resources and Expertise
Resource constraints shape practical choices:
- NPWT is widely available in most centers
- Specialized traction systems require training and may not be universally accessible
- Simpler techniques cost less upfront but may increase long-term complication expenses
- Balance immediate costs against potential hernia repair expenses
Factor 5 - Goal of Care
Define your endpoint early. Is the goal primary fascial closure (use traction systems aggressively) or damage control with planned hernia (mesh bridge acceptable)? EAST and WSES guidelines conditionally recommend fascial traction systems over routine care to maximize closure rates.
Common Mistakes When Selecting Temporary Abdominal Closure Techniques
Mistake 1: Using NPWT alone for prolonged periods without fascial traction
The probability of achieving primary fascial closure declines significantly after 7-10 days due to lateral fascial retraction. Without active tension, fascial edges migrate laterally, making closure increasingly difficult.
Research shows closure rates drop from 70% in the first week to below 50% after 10 days with NPWT alone.
Mistake 2: Delaying transition to definitive closure
Every additional day with open abdomen increases risk of fistula, infection, and loss of domain. Optimal outcomes are achieved when definitive closure occurs within 4-7 days, as delays beyond this window exponentially increase complications.
Mistake 3: Choosing technique based on availability rather than optimal fit
While resource constraints are real, using suboptimal techniques when better options exist compromises outcomes and may increase long-term costs through complications.
The upfront cost of traction systems is often offset by reduced complication rates and shorter time to closure.
Conclusion
Temporary abdominal closure is a critical bridge in damage control surgery, with multiple techniques available that differ in mechanism, invasiveness, and outcomes.
The goal is always early primary fascial closure when physiologically possible, as this significantly reduces morbidity and improves long-term quality of life.
Evidence supports combining NPWT with dynamic fascial traction to achieve closure rates of 80-98%, far superior to NPWT alone. The critical 7-day window represents the optimal timeframe for definitive closure—beyond this, complications rise exponentially.
After achieving fascial closure, bioabsorbable skin closure systems like SubQ It! offer alternatives to traditional metal staples, eliminating the need for staple removal while improving cosmetic outcomes.
Frequently Asked Questions
What is the Jenkins rule for abdominal closure?
The Jenkins rule (4:1 rule) states that suture length should be at least four times the wound length to reduce hernia risk. This ratio distributes tension evenly, significantly reducing wound dehiscence and incisional hernia rates.
What are the different devices used for temporary abdominal wound closure?
Main categories include negative pressure wound therapy systems (VAC, ABThera), fascial traction devices (Wittmann Patch, AbClo, ABRA), mesh products, plastic silos (Bogotá bag), and skin approximation systems (towel clips, zippers).
When should temporary abdominal closure be converted to definitive closure?
Definitive closure should be attempted as soon as the patient is physiologically stable, source control is achieved, and intra-abdominal edema has resolved—ideally within 5-7 days.
What is the risk of leaving an abdomen open for too long?
Prolonged open abdomen (>7-10 days) significantly increases risk of enteroatmospheric fistula (up to 25%), loss of abdominal domain, complex ventral hernias, and infection, with primary closure probability declining sharply after the first week.
How does negative pressure wound therapy work in temporary abdominal closure?
NPWT applies controlled suction (typically -125 mmHg) through a foam or gauze interface to remove fluid, reduce edema, and promote granulation tissue. However, it does not provide active fascial traction to prevent lateral retraction.
Can temporary abdominal closure techniques be combined?
Yes, combination approaches (e.g., NPWT + fascial traction) are common and often superior. They enable both fluid management and active fascial approximation, achieving closure rates of 80-98% versus 50-70% for NPWT alone.
