Pathogenesis and etiology of the open
means a non-union of the abdominal wall.
Often this results from surgical site
infections or wound complications.
Infections might be superficial, limited to
skin, subcutaneous fatty tissue or muscles.
More frequently it originates from the
abdominal cavity. A wound dehiscence of
superficial layers of the abdominal wall is
called incomplete burst abdomen. If all
layers are opened the term complete burst
abdomen is applied.
A cause for development of an open abdomen
might be an inadequate surgical technique.
This can be related to kind of suture,
chosen material or surgical approach. The
most important risk factor is the patient
itself with its comorbidities, age,
medication and local vascular disorders.
The open abdomen is a severe disease
accompanied by high morbidity and mortality.
Treatment on the intensive care unit is part
of the initial course. The duration of
treatment on the ICU ranges from 17 to 65
days. In spite of complex and expensive
treatment mortality is as high as 52%. Most
common reasons for death are sepsis and
multiple organ failure. Overall length of
stay in hospital ranges from 45 to 92 days.
Besides various problems of intensive care
medicine the open abdomen is accompanied by
specific challenges. These are formation of
intestinal fistulae, bowel movement
disorders, intraabdominal bleeding and
The open abdomen demands combined efforts of
patients, nurses and surgeons. The aim of
treating an open abdomen must be a closure
of the abdominal wall as fast as possible.
Unfortunately, this is not always possible.
Therefore, a temporary closure of the open
abdomen might be necessary. The chosen
technique of temporary abdominal closure
determines rate of complications as well as
rate of final abdominal closure.
closure of the open abdomen
treatment on the ICU is characterized by
respiratory disorders, loss of proteins and
fluids, imbalance of electrolytes,
considerable limitation of patients mobility,
pain, infections and intestinal fistulation.
Therefore, temporary closure of the open
abdomen is imperative.
is prevention of complications and reduction
of treatment efforts. Furthermore, it should
support planned final abdominal closure.
temporary abdominal closure should meet the
- conservation of the abdominal wall
- prevention of lateral retraction of the
- support of planned final abdominal closure
- possibility of multiple surgical
reexplorations while being easily applicable
- short duration of dressing change
- prevention of external re-contamination of
the abdominal cavity
- protection against desiccation and damage
- prevention of herniation and evisceration
- prevention and treatment of abdominal
- reduction of loss of fluids as well as
of patient care
- patient compliance and convenience
- prevention of late complications like
incisional hernia, intraabdominal adhesions
- cost reduction by shortening ICU and
hospital length of stay
To date, none of the published procedures,
meets all of the mentioned requirements.
Otherwise, depending on the chosen technique,
considerable differences regarding frequency
of complications and rate of final abdominal
closure, exist. Vacuum therapy seems to be
one of the most effective. This technique is
published using different terms like vacuum
assisted closure or negative pressure wound
therapy or active wound drainage
of intestinal fistulae is a severe
complication of treating an open abdomen.
Frequency ranges between 4 to 41%, and
mortality is increased by 30 to 60%.
reason for occurrence of intestinal fistulae
is not always apparently. Often it indicates
the severity of the underlying disease. The
prognosis depends on various factors. The
origin of the fistula can be assigned to
small intestine or colon. Size and volume
output are also of importance. Spontaneous
closure of enteric fistulae can be expected
in 30 to 70% of cases. Fistulae open out
into an open abdomen are less likely to
close spontaneously. The rate is as low as 6
possible a surgical closure of the fistulae
should be attempted. In some cases suturing
might be sufficient. In other cases
extensive division of adhesions and
resection of parts of the small intestine or
colon is necessary. Other possibilities are
use of adhesives or coagulation activating
agents. Unfortunately, sufficient closure of
intestinal fistulae is not always achievable.
treatment of an open abdomen or recurrent
attempts of closing enteric fistulae might
lead to formation of a frozen abdomen. This
means a tight adhesion of intestines with
the abdominal wall. Usually this results in
extensive wound areas. Fistulae ending in
these areas are called enteroatmospheric, in
contrast to enterocutaneous fistulae open
out into the skin. In most cases, a usual
ostomy care is not feasible. Wound care is
time consuming and costly. Use of various
catheters for drainage often leads to
therapeutic option – PPM-Fisteladapter™
of negative pressure wound therapy has
improved open abdomen treatment in many ways.
Unfortunately handling of intestinal
fistulae remains a serious problem. Suction,
applied via sponge to the wound surface,
often leads to enlargement of the fistula or
eventration of the mucosa. Additionally,
viscous stool might obstruct the sponge.
This results in separation of sponge and
wound surface. The suction becomes
insufficient and may lead to contamination
or infection of the wound.
drain-out systems using negative pressure
wound therapy have been published.
Unfortunately none of them is reliable.
Individual, time-consuming modifications are
necessary in most cases.
This led to
extensive research in the Department of
General, Visceral and Vascular Surgery of
the University Hospital Magdeburg. The
result was the development of the fistula
adapter by Dr. Tautenhahn, Prof. Lippert and
Primed Halberstadt Medizintechnik GmbH. By
now, there are 4 types of the fistula
adapter available, for managing
original adapter with a height of 3 cm has
an inner diameter of 1.5 cm. The lower brim
transfers the negative pressure to the wound
preventing dislocation. The upper brim
serves for fixation of an ostomy bag. The
height of the adapter is adjusted to the
usual thickness of the negative pressure
wound therapy sponge.
initial trial 15 patients were treated using
the novel fistula adapter. The device was
efficient and feasible. Duration for wound
dressing change could be reduced
considerably. Patients reported improved
comfort. Particularly, stability of the
wound dressing and possibility of patient
mobilization were beneficial. In this trial
problems occurred with two of the patients.
This led to development of different
modifications of the fistula adapter.
treatment of deep fistulae a 6 cm high
adapter with an inner diameter of 1.5cm is
now available. For fixation two
super-imposed sponges are used. For
management of large sole fistulae or
multiple small fistulae being close to each
other an adapter of 3 cm height and an inner
diameter of 4.5 cm can be used. Due to its
flexibility it might be fixed in an oval