What Standardized Care Pathways Can Teach Us About Open Abdomen Management
Open abdomen management remains one of the most demanding challenges in trauma and acute care surgery. While advances in damage control surgery, resuscitation, and critical care have improved survival for severely ill patients, achieving timely primary fascial closure continues to be a significant obstacle.
The longer an abdomen remains open, the greater the risk of fascial retraction, loss of domain, prolonged intensive care stays, multiple return trips to the operating room, and long-term complications such as incisional hernia. These challenges have led many institutions to move beyond individual surgeon preference and toward protocolized approaches designed to improve consistency and closure outcomes.
During the AbClo Symposium at the Mattox TCCACS & MDR 2026 conference, trauma surgeons from two high-volume trauma centers shared their experiences developing structured pathways for open abdomen management. While their institutions differ in size, patient populations, and workflows, a common theme emerged: successful closure often begins with standardized processes rather than isolated interventions.
Why Open Abdomen Management Remains Challenging
The open abdomen is rarely a static clinical situation.
Following laparotomy, the abdominal wall is subjected to ongoing edema, inflammation, fluid shifts, and lateral fascial tension. As time passes, these forces can progressively separate fascial edges, making primary fascial closure increasingly difficult.
A recent practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) recognizes the ongoing challenges associated with prolonged open abdomen management and conditionally recommends the use of fascial traction systems once intra-abdominal pathology has been addressed. The guideline concluded that fascial traction techniques improve rates of primary myofascial closure without increasing mortality or enterocutaneous fistula formation. Despite these advances, fascial retraction, loss of domain, and delayed closure continue to present significant clinical challenges in both trauma and emergency general surgery.
For this reason, many trauma centers are placing greater emphasis on early intervention strategies that aim to prevent fascial retraction before it becomes a larger problem.
The Cost of Inconsistency in Open Abdomen Care
One of the recurring themes discussed during the symposium was the danger of variability.
Open abdomen patients often move between the operating room, intensive care unit, nursing teams, advanced practice providers, fellows, residents, and attending surgeons. Without a clearly defined pathway, key decisions regarding monitoring, re-evaluation, and closure planning can become inconsistent.
Dr. Shiree Berry emphasized that open abdomen patients must be managed “expeditiously, consistently, and efficiently” to avoid preventable complications and prolonged periods before fascial closure. Her institution’s protocol was developed specifically to reduce variability and establish a more standardized approach to patient care.
This concept reflects a broader trend in trauma care: improving outcomes often depends as much on process optimization as it does on technology or technique.
How HCA Houston Northwest Approaches High-Risk Open Abdomen Cases
As a high-acuity Level II trauma center with significant acute care surgery volume, HCA Houston Northwest frequently manages patients at elevated risk for loss of domain.
According to Dr. Berry, the institution developed a protocol focused on identifying high-risk patients early and implementing closure strategies before fascial retraction becomes severe.
Factors considered during initial evaluation include:
- Body mass index greater than 30.
- Anticipated prolonged open abdomen duration.
- Abdominal compartment syndrome.
- Underlying pathology likely to require multiple take-back operations.
The objective is straightforward: establish a standardized pathway that supports timely care and reduces the risk of complications associated with delayed closure.
Importantly, the protocol extends beyond surgeons alone. Dr. Berry emphasized the need for education across the entire care team, including trauma surgeons, fellows, residents, advanced practice providers, operating room personnel, and surgical intensive care unit staff.
How WellSpan Integrated Open Abdomen Management Into ICU Workflow
WellSpan York Hospital faces similar challenges, managing approximately 35 to 45 open abdomen cases annually across trauma, vascular, and emergency general surgery populations.
Recognizing the difficulty of predicting when patients may return to the operating room, the institution incorporated fascial traction into a broader open abdomen management pathway designed to reduce delays in care.
Dr. Joshua Hazelton described a workflow in which open abdomen management extends beyond the operating room and into the trauma surgical ICU. The institution stores AbClo in the ICU rather than the OR and developed standardized documentation, nursing orders, monitoring procedures, and device management protocols to support consistent application.
This approach reflects a key insight: open abdomen management is not solely an operative challenge. It is a multidisciplinary process that continues throughout the patient’s critical care journey.
Common Themes Across Both Programs
Although developed independently, both institutions identified several common principles associated with successful open abdomen management.
Early Identification of Risk
Patients with obesity, severe contamination, abdominal compartment syndrome, or anticipated multiple take-backs were recognized as requiring additional attention early in their treatment course.
Standardized Care Pathways
Both centers emphasized the importance of reducing variability through protocols, guidelines, and predefined workflows.
Team-Wide Education
Open abdomen management involves far more than the operating surgeon. Nursing staff, residents, fellows, advanced practice providers, and ICU teams all play a role in achieving successful outcomes.
Early Fascial Stabilization
Preventing progressive fascial retraction remains a central objective. Both presenters highlighted the importance of addressing closure challenges before significant loss of domain develops.
What Other Trauma Centers Can Learn
Not every trauma center has the same resources, staffing model, or patient population. However, the lessons presented during the symposium suggest that several principles may be broadly applicable.
Open abdomen management benefits from:
- Clear closure goals.
- Early identification of high-risk patients.
- Consistent monitoring practices.
- Defined multidisciplinary responsibilities.
- Standardized documentation and communication pathways.
These strategies help create an environment where closure planning begins early rather than becoming a reactive process after significant fascial retraction has already occurred.
The Future of Protocolized Open Abdomen Management
As more institutions adopt structured approaches to open abdomen care, the next challenge is understanding which protocols produce the best outcomes.
To support this effort, symposium presenters discussed the development of an AbClo registry designed to collect prospective observational data across participating trauma centers. The initiative aims to compare current patient outcomes with historical controls while laying the foundation for larger multicenter analyses in the future.
As evidence continues to evolve, protocolized open abdomen management may become an increasingly important component of achieving reliable primary fascial closure while reducing the long-term burden of complications.
References
- Berry S. Management of Complex Open Abdomen Cases with AbClo. Presented at: Mattox TCCACS & MDR 2026 Satellite Luncheon; April 27, 2026; Las Vegas, NV.
- Hazelton J. Management of Complex Open Abdomen Cases with AbClo. Presented at: Mattox TCCACS & MDR 2026 Satellite Luncheon; April 27, 2026; Las Vegas, NV.
- Rezende-Neto J. Management of Complex Open Abdomen Cases with AbClo. Presented at: Mattox TCCACS & MDR 2026 Satellite Luncheon; April 27, 2026; Las Vegas, NV.
- Mahoney EJ, Bugaev N, Appelbaum R, et al. Management of the Open Abdomen: A Systematic Review with Meta-Analysis and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2022;93(3):e110-e118. doi:10.1097/TA.0000000000003683.