Deep exposed fistulae evolve into a complex pathology that lead to tremendous metabolic drain from uncontrolled peritonitis. Levy and colleagues, [17] a group that pioneered open management of severe abdominal infection , reported 120 cases from their referral center in Paris in 1986 and coined the term exposed fistula to denote an enteroatmospheric fistula in an open (or dehisced) abdomen. The first report in the English literature was by Schein and Decker [23] from Johannesburg, who described the entity in detail and reported a 60 % mortality rate, despite adherence to modern principles of fistula management. This is an intraperitoneal process with unbridled egress of intestinal effluent in the abdominal cavity. The underlying principle that guides management is conversion of this process to a wound management problem.

Negative pressure dressings showed early promise, but have anecdotally shown to result in more fistulization when placed directly on granulating abdominal viscera and therefore should be avoided. In fact, an alert issued by the Food and Drug Administration (FDA) in November 2009 warned against the use of these dressings on exposed enteric fistulas because of serious complications [10]. In a frozen abdomen, inserting tubes and catheters in fistulae is again ill-advised as these methods only make the defect larger and prevent healing. It is also inadvisable to repair this type of fistula acutely in the inflamed surgical field and in a malnourished patient. Elective repair of the fistula should be delayed for several months when the fistula can be resected in conjunction with a delayed abdominal wall reconstruction . A planned ventral hernia with control of the effluent is usually the safest option. Intubation of the fistula through a protective wound VAC, the so-called tube VAC devised by George Al-Khoury in 2007 while working with the Hirschberg group, has been described to be successful in several select cases [14, 15].

Schein [22] from South Africa described simple measures for management of enteroatmospheric fistulae by exteriorizing a leaking segment or proximal diversion if possible. Another elegant technique was described by Hirschberg et al. in 2002 [24]. They proposed using a Bogota bag (sterile IV fluid bag used in temporary closures in the 1990s), suturing it to the skin and a making hole over the fistula. This serves as a physical barrier that protects the peritoneum. An ostomy bag can then be placed while granulation continues underneath.

Morbidity associated with wound complication from the open abdomen remains high (25 %) and is associated with the timing and method of closure and transfusion volume, but is independent of injury severity. Delayed primary fascial closure before 8 days is associated with the best outcomes at the least charges. However, attempts at fascial closure under undue tension are fraught with significant morbidity and mortality [18–21].

Abscesses are frequently a result of undrained cytokine-rich collections in the dependent recesses of the abdomen. Timely take backs to the operating room for abdominal washouts as well as effective temporary abdominal closure with quantifiable suction to remove this toxic fluid is essential for prevention. Abscess rates between the two groups were similar. At each VAC re-exploration, very few intra-abdominal abscesses were found. Most of the abscesses were diagnosed well after polyglactin mesh placement in both groups. As expected, those patients who had hollow viscus injury or gauze packing placed were more likely to develop abdominal abscesses.

The key is prevention by utilizing early closure, limiting fluids, utilizing an effective temporary closure, and selective use of biologic materials.