Damage-control surgery and abdominal compartment syndrome

• Damage-control surgery is a staged operation for the patient who is too sick to tolerate a complete operation in one sitting. The first stage stops bleeding and contamination, packs the abdomen if needed, and leaves it open; the patient is stabilised in the intensive care unit (ICU); and a planned re-look operation finishes the repair later.
• It is not the first operation after every injury. It is chosen when the patient already has, or is about to have, the lethal triad of hypothermia, acidosis and coagulopathy, or when bleeding cannot be fully controlled, or when the abdomen cannot be closed safely.
• An open abdomen is left with a temporary abdominal closure (skin and fascia not fully closed). It protects the patient from abdominal compartment syndrome, permits re-exploration, and allows the abdominal wall to stay elastic. ^[1][2]
• Intra-abdominal hypertension (IAH) is a sustained intra-abdominal pressure (IAP) of 12 mmHg or more. Abdominal compartment syndrome (ACS) is a sustained IAP above 20 mmHg with new organ dysfunction. Both are measured through the bladder, not by examination. ^[2]
• ACS kills when it is missed. A burst abdomen, oliguria, rising ventilation pressures or haemodynamic collapse in a patient with a tight, distended abdomen after surgery or resuscitation should prompt immediate bladder pressure measurement and, if confirmed, decompression.
• Packing and open abdomen are life-saving but costly: enterocutaneous or enteroatmospheric fistula, frozen abdomen and failure to close the fascia are the price of delay. ^[1]

By the end of this page you should be able to:

1. Explain when an abbreviated (damage-control) laparotomy is safer than a definitive operation.
2. Outline the three phases of damage-control surgery and what is done in each.
3. Describe packing and temporary abdominal closure, with their indications and cautions.
4. Define IAH and ACS, grade IAH, and measure IAP through the bladder.
5. Run the medical management of IAH and decide when decompressive laparotomy is needed.
6. Care for an open abdomen: nutrition, closure strategy, timing of re-exploration and complications.
7. Adjust the approach for non-trauma, sepsis, vascular and pancreatic disease, and for children.

Severe bleeding or severe sepsis in the abdomen creates a problem for the surgeon that is different from the usual one. A technically perfect operation takes time; blood loss and fluid shifts during that time can push the patient into hypothermia, acidosis and coagulopathy, the "lethal triad." Once that triad is established, trying to finish every repair makes the bleeding worse. The answer is to do the minimum that will keep the patient alive now, and to come back later when the physiology has been restored. That principle is damage-control surgery (DCS), and the first operation is called a damage-control or abbreviated laparotomy ^[1].

Damage-control surgery is usually part of a wider damage-control approach that includes damage-control resuscitation: permissive hypotension where appropriate, limitation of crystalloid, and blood products given in balanced ratios ^[2]. The surgery and the resuscitation earn each other time; neither is sufficient alone.

An open abdomen after DCS is not a failure to close. It is a deliberate strategy to avoid IAH and ACS, to allow re-exploration for packing removal or a second look at the bowel, and to prevent abdominal wall tension. The trade is a high risk of fistula, infection and later herniation if the abdomen stays open too long ^[1].

This page follows the available consensus documents: the World Society of Emergency Surgery (WSES) 2018 guidelines on the open abdomen ^[1], the 2013 consensus definitions and management statements of the World Society of the Abdominal Compartment Syndrome (WSACS) ^[2], and the trauma-course framework of Advanced Trauma Life Support (ATLS) ^[3]. No newer WSACS surgical guideline is open at the time of writing; the 2013 document is the one cited here, pending its revision.

The goal of the first laparotomy is not anatomical perfection. It is to stop exsanguination and sepsis from infection. Definitive repair of anastomoses, closure of fascia and planned re-exploration follow when the core temperature, acid-base status and clotting are restored ^[1].

1. First operation in theatre: control haemorrhage and contamination; pack if bleeding is not fully controlled; place a temporary abdominal closure; do not attempt definitive reconstruction.
2. ICU resuscitation: rewarming, correction of acidosis and coagulopathy, balanced volume and pressor support, treatment of hypoxia; measurement of IAP.
3. Planned re-look operation: remove packs, complete repairs, restore intestinal continuity where deferred, and work toward fascial closure.

A fourth phase, recovery and definitive abdominal wall reconstruction, follows once the patient is stabilised ^[1].

The WSES and WSACS both define the open abdomen as one in which the skin and fascia are not closed after laparotomy, and which therefore needs a temporary abdominal closure ^[1][2]. Temporary abdominal closure is the method that protects the viscera while the fascia remains open: a visceral drape plus a protective layer and, in most centres, negative pressure, with effort to maintain medial traction on the fascia ^[1].

Temporary abdominal closure without negative pressure (for example a Bogota bag) can be used in low-resource settings, accepting a lower delayed fascial closure rate and a higher intestinal fistula rate ^[1]. Negative pressure wound therapy (NPWT) with continuous fascial traction is the preferred temporary closure technique in the WSES guidance ^[1]. NPWT should be down-regulated when there is coagulopathy or a high risk of bleeding, balancing the benefit of negative pressure against haemorrhage risk ^[1].

Table 1 gives the WSACS grading used throughout this page. The same numerical bands are used in adults and are adopted by WSES for the open-abdomen context ^[1][2].

The abdominal perfusion pressure is mean arterial pressure minus IAP. The 2013 panel made no recommendation for using it as a resuscitation endpoint, so local practice governs ^[2].

Damage-control surgery is practised predominantly in major trauma centres, but an increasing proportion is performed in emergency general surgery and vascular surgery. WSES estimates that about 20% of patients after repair of a ruptured abdominal aortic aneurysm develop ACS, with mortality of 30 to 50%, almost doubled in the presence of ACS ^[1]. The open abdomen itself is associated with considerable morbidity and with mortality often up to about 50% even after decompression ^[2]. These poor outcomes are better understood as the price of the injuries and physiology that mandated DCS than as a failure of the technique, but they are the reason that DCS must be applied selectively.

Primary IAH or ACS arises from disease or injury in the abdominopelvic region; secondary IAH or ACS arises from conditions outside it, such as large-volume resuscitation or burns; recurrent IAH or ACS returns after previous treatment ^[2].

Damage-control laparotomy is triggered by physiology rather than by anatomy. The strong predictors identified in WSES 2018 are persistent hypotension, acidosis with pH below 7.2, hypothermia below 34 degrees C, and coagulopathy ^[1]. Other recognised risk factors for IAH that should be borne in mind are obesity, pancreatitis, hepatic failure or cirrhosis, positive end-expiratory pressure above 10 cm H2O, respiratory failure and acute respiratory distress syndrome ^[1].

In trauma, the threshold bundle used in WSES 2018 is a practical summary: acidosis with pH 7.2 or less, lactate 5 mmol/L or more, base deficit of minus 6 or worse in patients over 55 years (minus 15 or worse in younger patients), core temperature 34 degrees C or less, systolic pressure 70 mmHg or less, estimated blood loss 4 L or more, transfusion of 10 units or more of packed red cells, and severe coagulation derangement with INR or prothrombin time above 1.5 times normal with or without partial thromboplastin time above 1.5 times normal ^[1]. No single item dictates the decision; it is the combination, and the trajectory, that matter.

Severe sepsis and an inability to control the source of infection at the index operation are further indications to consider a staged approach, particularly when bowel perfusion is in doubt or there is abdominal wall tissue loss ^[1].

The abdominal compartment is inelastic in the acute setting. Visceral oedema, retroperitoneal swelling, haematoma, ascites and large-volume fluid resuscitation all reduce abdominal compliance. Once a critical volume is exceeded, small additional volume produces large rises in pressure. Rising IAP compresses the inferior vena cava and splanchnic circulation, increases the work of breathing and reduces cardiac preload and renal perfusion. Left unchecked, IAH progresses to ACS, with oliguria, hypoxaemia, reduced cardiac output and, eventually, multi-organ failure ^[2].

The same mechanism explains why DCS helps. By packing and stopping the operation early, further fluid shifts and hypothermia are avoided. Temporarily leaving the abdomen open removes the pressure before it becomes dangerous. Continuous clinical judgement is still needed, because re-closure or re-accumulation can re-create the syndrome ^[1].

The "lethal triad" narrative belongs to the same physiology. Surgery in a cold, acidotic, coagulopathic patient leads to diffuse bleeding; the answer is to truncate the procedure, resuscitate aggressively with warmed blood products in balanced ratios, and operate again later ^[1][3]. ATLS (10th edition manual 2018; ATLS 11 released in 2025) frames trauma care as an xABCDE approach and has been taught to more than one million clinicians in more than 80 countries; within it, damage-control concepts belong to the same primary-survey and resuscitation sequence ^[3].

These patients are not "stable with an abdomen." Expect a patient who is cold, hypotensive, tachycardic, with ongoing haemorrhage, transfusion requirement, or a rapidly rising lactate. On the operating table, oozing from raw surfaces that will not clot, diffuse tissue oedema and a tense, distended abdomen are the clinical clues ^[1]. In severe peritonitis, physiological exhaustion (high vasopressor requirement, rising lactate, oliguria) rather than a single anatomical finding is what matters ^[1].

Clinical examination is inaccurate for detecting raised IAP. IAH and ACS must be measured, not estimated ^[1][2]. The risk-factor screen in Table 2 is the trigger to measure. Suspect IAH/ACS when a critically ill or injured patient develops one or more of the following:

• new oliguria or anuria despite adequate resuscitation;
• rising peak ventilation pressures or worsening hypoxaemia;
• haemodynamic instability with high filling pressures and low urine output;
• a tense, distended abdomen, or one that cannot be closed without excessive tension;
• unexplained multi-organ deterioration after shock, sepsis or major resuscitation.

Table 2 summarises the WSACS method, which WSES also accepts ^[1][2].

Normal IAP in critically ill adults is about 5 to 7 mmHg ^[2]. In critically ill children it is about 4 to 10 mmHg, IAH is a sustained or repeated pressure above 10 mmHg, and ACS is a sustained pressure above 10 mmHg with new or worsening organ dysfunction attributable to it ^[2].

The tight/dysfunctional abdomen after surgery or resuscitation can be confused with several other problems. Clinical context and a bladder pressure measurement separate them.

None of these differentials replaces a measurement. A patient who is at risk and deteriorates after DCS, resuscitation or sepsis surgery earns a bladder pressure reading.

Investigation proceeds in layers: bedside pressure measurement, then tests that identify the cause and organ dysfunction.

• IAP measurement (bladder) is the essential first test in any at-risk patient, and should be measured in all such patients ^[1].
• Full blood count, clotting screen and platelets to detect coagulopathy, transfusion need and trends.
• Arterial blood gas for pH, lactate and base deficit, both as a decision trigger and to track resuscitation.
• Renal function and urine output to detect renal perfusion compromise.
• Liver biochemistry and electrolytes, as guided by the clinical picture.
• Imaging is usually limited in the unstable, packed abdomen; CT or bedside ultrasound are used once the patient is stabilised or when a source of infection or ischaemia is suspected.
• Documentation of packs and devices before transfer to ICU, so that the re-look operation is planned accurately ^[1].

Exploratory investigation is discouraged in the patient who is still being resuscitated. The operation and the bladder pressure come first.

• IAH: sustained or repeated pathological elevation of IAP of 12 mmHg or more ^[2].
• ACS: sustained IAP above 20 mmHg, with or without abdominal perfusion pressure below 60 mmHg, associated with new organ dysfunction or failure ^[2].
• In children, IAH is a sustained or repeated pressure above 10 mmHg and ACS is a sustained pressure above 10 mmHg with new or worsening organ dysfunction attributable to elevated IAP ^[2].

The WSACS open-abdomen classification (modified from Bjorck) grades the state of the abdomen from 'no fixation, clean' through 'developing fixation' to 'frozen abdomen' and 'established enteroatmospheric fistula' ^[2]. It is a research and communication tool that reminds clinicians to avoid the late complications: fixation, fistula, and an abdomen that cannot be closed.

WSES summarises the predictors already given. A working memory aid is the combination of pH below 7.2, temperature below 34 degrees C, coagulopathy with INR or prothrombin time above 1.5 times normal, and hypotension or large transfusion requirement ^[1]. These are predictors, not obligations: a patient with one factor in isolation may still tolerate definitive surgery; a patient with the whole pattern should be abbreviated.

The sequence is standard trauma and critical care. Airway with cervical spine protection where indicated, breathing and oxygenation, circulation with haemorrhage control, and prompt activation of the trauma or surgical team ^[3]. Warm fluids, avoid unnecessary crystalloid, and give blood products in balanced ratios in massive haemorrhage ^[2].

• Abbreviate. Control haemorrhage with packing, vessel ligation or shunting, and control contamination with bowel resection and stapled stumps or simple diversion; do not attempt complex reconstruction in an unstable patient ^[1].
• Pack when bleeding is not fully controlled or when a second look will be needed. Non-absorbable packing is used temporarily, with a balance between haemostatic tamponade and vessel compression that could create IAH ^[1].
• Leave the abdomen open with a temporary abdominal closure that permits swelling without excessive pressure rise ^[1]. Fill the abdomen with packs and a protective layer; maintain medial traction on the fascia where possible.
• Document known injuries, packs and devices, and plan the re-look explicitly.
• Address hypothermia actively: warming blankets, warmed fluids and blood, and a covered abdomen where possible; commercial NPWT systems reduce heat loss more than home-made ones ^[1].
• Avoid hypotension as far as resuscitation allows; continuous cardiac-output-based or volumetric monitoring can help judge fluid status when intra-abdominal and intrathoracic pressures distort pressure-based measurements ^[1].

The WSES position is that DCS is a component of damage-control management together with damage-control resuscitation, and that prophylactic open abdomen is suggested for trauma patients in physiological exhaustion ^[1][2]. For trauma patients, an open abdomen is indicated when necessary, and IAP measurement is essential in those at risk ^[1].

Before decompressive laparotomy, apply protocolised medical management ^[2]:

1. Reduce intra-luminal contents: nasogastric and rectal tubes with enteral decompression when the stomach or colon are dilated; promotility agents such as neostigmine for established colonic ileus not responding to simpler measures ^[2].
2. Reduce abdominal wall tone: optimal pain and anxiety relief; brief trials of neuromuscular blockade as a temporising measure ^[2].
3. Positioning: recognise and manage the contribution of body position to raised IAP, including the angle of head-of-bed elevation ^[2].
4. Fluid balance: use a protocol to avoid a positive cumulative fluid balance after the initial resuscitation and once the inciting issues have been addressed ^[2]. WSES adds: avoid aggressive resuscitation, scrutinise fluid balance, and prefer small frequent boluses where possible ^[1].
5. Percutaneous drainage: where obvious intra-peritoneal fluid is present and drainage is technically possible, use a pigtail or PCD; this may alleviate the need for decompressive laparotomy ^[2].
6. Resuscitation strategy: in massive haemorrhage, use an enhanced ratio of plasma to packed red cells ^[2] (GRADE 2D; moderate strength only).
7. Avoid sustained IAH with protocolised monitoring and management rather than inattention to IAP ^[2].

WSACS made no recommendation on abdominal perfusion pressure targets, diuretics, renal replacement therapy or albumin for this purpose; clinicians should follow local critical-care practice ^[2].

WSACS recommends decompressive laparotomy in overt ACS compared with strategies that do not use it, in critically ill adults (GRADE 1D) ^[2]. WSES agrees: decompressive laparotomy is indicated in ACS when medical treatment has failed after repeated and reliable IAP measurements (GRADE 2B) ^[1]. Opening the abdomen produces an immediate fall in IAP and improvement in organ function, but it carries substantial complication risk and mortality up to about 50% even after decompression, largely because of the underlying disease ^[2].

The WSES and WSACS consensus is that medical and minimally invasive measures should be tried before the knife when the patient is stable enough to allow it; but if organ failure is progressing despite medical management, delay is dangerous. Decompression should be done in theatre with full trauma or intensive-care support, and the abdomen is then left open with a temporary closure.

WSES gives a further nuance: in severe peritonitis with contamination, an open abdomen is suggested only under specific circumstances—an abbreviated laparotomy because of severe physiological derangement, a deferred anastomosis, a planned second look for ischaemia, failure of source control, or concern for ACS—because routine open abdomen in severe contamination is not justified (GRADE 2B for not routinely using it) ^[1][2]. Clinicians should respect that nuance: do not leave the abdomen open for convenience when closure is safe ^[1].

The phased approach is where the plan succeeds or fails.

• Re-explore the open abdomen no later than 24 to 48 hours after the index and any subsequent operation. The interval should shorten with worsening physiology or haemodynamic instability (GRADE 1C, WSES) ^[1]. Trauma series suggest that each hour beyond 24 hours reduces the primary fascial closure rate, and that complication rates rise when the first re-operation is delayed beyond 48 hours ^[1].
• Remove all packing at the re-look and confirm haemostasis before definitive repair. Complete deferred anastomoses, address any second-look bowel concern, and begin washout.
• Maintain the abdomen open if resuscitation is ongoing, the source of contamination persists, a deferred anastomosis is still needed, a planned second look for ischaemia remains, or there is concern for ACS ^[1].
• Early fascial and abdominal closure is the goal once resuscitation is complete, source control is achieved, no viability concerns remain, no further re-exploration is needed, and there is no concern for ACS (GRADE 1B, WSES) ^[1]. The WSES and WSACS both emphasise conscious, protocolised efforts to achieve fascial closure before discharge in ICU patients with open wounds ^[1][2].

Placement of bioprosthetic or synthetic mesh for early closure is not recommended routinely; non-cross-linked biologic meshes may be considered in sublay position when the linea alba can be reconstructed, and planned ventral hernia remains an option in the complicated open abdomen ^[1][2]. Synthetic mesh as a fascial bridge after open abdomen is not recommended ^[1].

Definitive management completes the staged plan: restore continuity with anastomosis now that physiology is stable, repair all injuries, and close the abdominal wall without undue tension. If the rectus sheath cannot be brought together without IAH, or if there is skin and soft-tissue loss, options include skin grafting onto granulating bowel with a planned ventral hernia repair months later, component separation, and biologic or synthetic reinforcement on a case-by-case basis ^[1].

Component separation should not be used for temporary closure; it is a definitive-reconstruction technique only ^[1].

Drugs in DCS are resuscitative and supportive rather than curative. There are no specific DCS or ACS drug prescriptions in the guidelines; the important teaching points are:

• Neuromuscular blockade: brief trial as a temporising measure for IAH/ACS ^[2]. Dose, agent and duration are governed by local sedation and critical-care protocols; the effect is short-lived and monitoring of paralysis depth is required.
• Sedation and analgesia: ensure optimal relief; analgesia is preferred over deep hypnosis where feasible, to reduce opioid burden and facilitate extubation ^[1][2].
• Neostigmine for established colonic ileus associated with IAH unresponsive to simple measures ^[2].
• Diuretics, renal replacement therapy and albumin: the WSACS made no recommendation; use according to local critical-care practice, ensuring the patient is adequately resuscitated first ^[2].
• Antimicrobials: in contaminated surgery, broad-spectrum cover based on suspected organism and local resistance patterns; antimicrobial stewardship and source control are the priorities. The WSES IA-infections guidelines cover this separately.
• Massive transfusion: warmed blood, plasma and platelets in balanced ratios; high-ratio plasma to packed red cells is suggested (GRADE 2D) ^[2].
• Vasopressors and inotropes: titrated to patient condition and the surgery performed; goal-directed fluid therapy with small boluses rather than high-rate maintenance where possible ^[1].

No drug in this list reduces the need for decompression. They buy time or manage complications.

Packing and temporary closure are the core surgical content of DCS. The WSES guidance can be condensed to:

• Packing for persistent bleeding, major vascular injury in combination with physiological exhaustion, coagulopathic oozing, and cases where complete repair would prolong operating time. Non-absorbable packs are used; the surgeon balances haemostasis against abdominal hypertension ^[1].
• Temporary closure with NPWT and fascial traction where available; without negative pressure in low-resource settings with acceptance of lower closure rates and higher fistula rates ^[1].
• Re-exploration at 24 to 48 hours or earlier if the patient deteriorates.
• Fascial closure as soon as possible once the patient tolerates it; late or impossible closure leads to planned ventral hernia or component separation at reconstruction.

All patients with an open abdomen need daily attention to IAP until closure and stabilisation. Daily weights, rigorous fluid-balance review, temperature control, enteral or parenteral nutrition, and a documented closure plan (target day, technique, fallback) improve outcomes. The whole ICU team should review the abdomen daily, not only the surgeon.

Transfer a DCS or open-abdomen patient to a centre with ICU capacity, massive-transfusion capability and experienced abdominal surgeons whenever possible. A patient with ACS requiring decompression whose local team cannot manage the open abdomen after decompression should be moved. When tertiary transfer is unavailable, the immediate priority remains decompression and resuscitation at the nearest capable facility, with packs and temporary closure as needed.

• Enteroatmospheric fistula from exposed bowel against the temporary closure or negative pressure directly on the viscera; this is the most serious complication of a prolonged open abdomen. Avoid direct NPWT on bowel, cover bowel with plastic sheet, omentum or skin, and deeply bury anastomoses ^[1].
• Frozen abdomen: fixation of viscera to peritoneal sidewalls, making re-exploration and closure impossible.
• Intra-abdominal abscess and sepsis from contamination and packs left in situ too long.
• Failure to achieve fascial closure, leading to large ventral hernia requiring complex reconstruction later.
• Recurrent ACS inside the open abdomen when the temporary closure is too tight or fluid accumulates again. NPWT may itself contribute to recurrent ACS in some cases.
• Nutritional depletion: open abdomen patients are hypermetabolic and lose nitrogen; early nutritional support is mandatory ^[1].
• Hypothermia and bleeding from repeated operations.
• Late adhesions and enterocutaneous fistula from the initial trauma or surgery, distinct from those caused by the open abdomen itself.

Prognosis depends more on the underlying injury or disease and on the speed of physiological correction than on any single operative step. Patients who require DCS but are stabilised and closed early do much better than those in whom the abdomen stays open beyond a week. Late closure, recurrent ACS and fistula are the markers of poor outcome. Patients with planned ventral hernia or component-separation reconstruction generally recover good function if they survive the acute phase, but their recovery is prolonged.

Primary prevention of IAH is more effective than treating established ACS. Avoid excessive fluid resuscitation once bleeding is controlled; use balanced ratios; keep the abdomen and fluid balance under close review; and measure IAP early in any patient with risk factors. IAH prevention is explicit in the WSACS statements ("efforts and/or protocols to avoid sustained IAH") ^[2].

Secondary prevention is achieved by opening early when the abdomen cannot be closed safely and by using temporary closure that tolerates swelling. The strongest predictors above are the practical triggers for that decision ^[1].

Children. Children develop ACS at lower pressures. IAH is a sustained or repeated IAP above 10 mmHg and ACS is a sustained pressure above 10 mmHg with new or worsening organ dysfunction; normal IAP is about 4 to 10 mmHg. The smallest bladder instillation volume is 1 mL per kg (minimum 3 mL, maximum 25 mL) ^[2]. Six of the WSACS management recommendations were accepted as suitable for children (measurement, protocolised monitoring, PCD, decompressive laparotomy, NPWT for fascial closure, avoidance of positive fluid balance); recommendations on components that were not supported for adults were also not accepted for children ^[2]. DCS concepts translate directly; physiology thresholds are adjusted by age and by weight rather than by adult cut-offs.

Pregnancy. Pregnancy elevates baseline IAP, and the gravid uterus compresses the inferior vena cava when the patient is supine. Lateral tilt during resuscitation, early obstetric involvement, and measurement with these factors recognised are required. Decompression or delivery may be needed for severe ACS; this is a specialist, multi-team decision.

Older adults and the frail. Physiological reserve is lower, and the decision to abbreviate is made sooner. Age alone is not a contraindication to DCS or to an open abdomen; what matters is deranged physiology and whether the patient was independent beforehand ^[1].

Massive transfusion and coagulopathy. Fresh frozen plasma and platelets in an enhanced ratio should be available before and during DCS; haematology and transfusion team involvement is standard.

Low-resource practice is not an excuse for guesswork; it is a reason to simplify safely.

• DCS itself is a low-resource technique: gauze packing and a Bogota bag are cheaper than a full kit, and they save lives ^[1]. Accept lower closure rates and higher fistula rates, and plan transfer if reconstruction is needed.
• Without a disposable pressure transducer, use the hand-held manometer or a simple fluid-column technique through the bladder. The principle (instil saline, measure at end-expiration, zero at the mid-axillary line) is the same ^[2].
• When NPWT is unavailable, use any temporary closure that keeps the bowel covered and prevents evisceration; a Silastic vacuum pack can be assembled from standard equipment.
• Decompression cannot wait for a tertiary centre. If the patient has ACS by measurement or by strong clinical suspicion (oliguria, ventilatory compromise, circulatory collapse with a tight abdomen), open the abdomen at the nearest facility that can.
• In low-volume hospitals, the decision thresholds, transfusion capacity and ICU resources available may mean more liberal use of packing and more frequent planned re-look operations.
• Reconstruction of a large ventral hernia after a prolonged open abdomen is usually deferred to a specialist centre; plan for it from the first operation.

• Damage-control surgery abbreviates the first laparotomy to stop bleeding and contamination, then repairs definitively after ICU resuscitation; it is chosen for physiological exhaustion, not for every serious injury.
• The lethal triad is hypothermia, acidosis and coagulopathy; the operation and the resuscitation are managed together.
• In trauma, the predictors are pH below 7.2, temperature below 34 degrees C, coagulopathy with INR or prothrombin time above 1.5 times normal, hypotension, large estimated blood loss, and heavy transfusion requirement.
• Non-trauma indications include severe sepsis with physiological exhaustion, ruptured abdominal aortic aneurysm, acute mesenteric ischaemia, and selected cases of severe pancreatitis.
• An open abdomen is a deliberate strategy requiring temporary closure; WSES prefers NPWT with fascial traction and accepts temporary closure without negative pressure in low-resource settings.
• Packing is a temporary bridge, not a destination; remove all packs at the re-look.
• Re-explore by 24 to 48 hours, earlier if unstable; work toward fascial closure as soon as physiology allows.
• IAP is measured through the bladder: up to 25 mL sterile saline, end-expiration, supine, transducer at the mid-axillary line. ^[2]
• IAH is sustained or repeated IAP of 12 mmHg or more (above 10 mmHg in children); ACS is sustained IAP above 20 mmHg with new organ dysfunction (above 10 mmHg in children).
• Grades: I (12 to 15), II (16 to 20), III (21 to 25), IV (above 25) mmHg. Normal adult IAP is about 5 to 7 mmHg.
• Medical management before decompression: decompress gut, reduce wall tone, adjust position, avoid positive fluid balance, drain obvious fluid, and use targeted resuscitation.
• Decompressive laparotomy is recommended for overt ACS in adults and for failed medical management even in sepsis and peritonitis, with the nuanced exceptions noted above. ^[2]
• Children develop ACS at lower pressures; adjust volumes and thresholds by weight.
• Long-term sequelae of a prolonged open abdomen include fistula, frozen abdomen and ventral hernia; prevent them with nutrition, early closure planning and meticulous technique.

Acute abdomen and intestinal obstruction; haemorrhagic shock and damage-control resuscitation; sepsis and source control; massive transfusion protocols; acute kidney injury; ARDS and mechanical ventilation; ventral hernia and abdominal-wall reconstruction; blunt and penetrating abdominal trauma; severe acute pancreatitis.

References are listed in the front matter. Each is cited above with a numbered reference: WSES 2018 open-abdomen guidelines (1), WSACS 2013 consensus definitions and management (2), and ATLS programme (3).