Originally described by Cohn et al. in 1995 [7] , an Esmarch bandage (latex or latex free) was first used to span the gap across the abdominal wall defect. The lateral aspect of each sheet was stapled to the skin and the medial aspects were brought together in the midline. The edges were then turned in and stapled, creating a silo. They were then folded down resulting in a tension-free closure. An iodophore-impregnated plastic sheet was then placed over the abdominal wall. Advantages included nonadherence to the bowel, cost-effectiveness, and feasibility. However, abdominal drainage did not occur with this closure either.

The concept of covering the abdominal contents with a silastic/plastic bag was developed in 1987 in Bogotá, Colombia by Borraez. He used a 3-L intravenous fluid bag as an abdominal covering. A time-honored method, its advantages include reduction in the rate of intra-abdominal infections seen with the previous use of sterile OR towels. This closure enabled bedside inspection of the abdominal contents through a clear, biologically inert dressing when refractory ischemia or bleeding was a concern. With resolving bowel edema, the abdominal viscera slowly reduced back into the abdominal cavity and the bag was truncated and resecured with metal clips to maintain domain [12, 18, 19].

A diverse assortment of synthetic mesh has been used to cover the bowel to manage the open abdomen. Marlex polypropylene mesh (Davol Inc, Providence, RI) is a porous material that allows drainage of intra-abdominal fluid. The rate of intestinal fistula formation ranges from 35 to 75 % with its use. Additionally, polypropylene mesh is difficult to remove at the time of primary closure. Knitted Dexon polyglycolic acid mesh (Davis and Geck, Inc., Danbury, CT) is an absorbable similarly porous synthetic mesh that has been used in cases of intra-abdominal sepsis . However, Dexon will frequently stretch under tension allowing for loss of domain and subsequent large ventral hernia defects. Goretex (W. L. Gore & Associates, Elkton, MD) is a soft, flexible, compliant counterpart that is desirable since it does not stretch while achieving abdominal coverage, but could also lead to ventral hernia formation.

Obtained at a local retailer, autoclaved, and attached to Marlex mesh then sutured to the fascia, a nylon zipper was described by Bose et al. [3] as a new closure method. This was then covered with saline-soaked or iodine-soaked gauze and surgical pads. Shortly thereafter, medical device manufactures began producing their own form of the nylon zipper. Ethizip (Ethicon, Somerville, NJ) is one commercially available abdominal zipper device. Zipper closure allowed easy reexploration and access for repeated lavages without fascial or mesh disruption while avoiding repetitive tissue trauma from suturing [3, 4, 8, 13, 14, 20].

Management of the open abdomen with a burr-like material has been described throughout the literature. Wittmann and Aprahamian et al. [33] described suturing the material to the fascial edges to protect the bowel and placing roller gauze over the burr. The patient was then returned to the operating room 24–48 h later for relaparotomy. The benefits of relaparotomy were recognition of continued hemorrhage, anastomotic dehisicence or leakage, and intestinal ischemia which were all treated at relaparotomy.

Following this, Wittmann described the tensile strength of the burr-like device noting that the device was unaffected until the fifth relaparotomy. In patients requiring multiple abdominal explorations, resuturing the fascia leads to necrotic edges, which is avoidable with the burr. The rate of abdominal closure was found to be comparable to other modalities.

In 1995, Brock and Barker et al. described a rapid, simple, and cost-effective method of temporarily covering the open abdomen. A fenestrated piece of polyethylene was placed over the abdominal viscera, beneath the parietal peritoneum and fascia. A moist laparotomy pad was placed between the open edges of fascia on top of the polyethylene sheet. Two sump drains were then placed over the moist laparotomy pad followed by application of an adhesive-backed drape over the entire wound and well onto the abdominal wall. The drains were placed to suction creating rigid compression of the dressing layers facilitating drainage of the abdomen. This method was modified in 1998 with the addition of an iodophore-impregnated adhesive plastic and the use of spray adhesive to facilitate adhesion of the outer sheet to the abdominal wall. The authors recommend at least 10 cm of abdominal wall overlap of the plastic sheet. This method protects the abdominal viscera from desiccation and heat loss as well as decreases the rate abdominal compartment syndrome . It could be applied in a matter of minutes as it avoids any suturing, allows for rapid reentry, and is cost-effective. Note that evisceration can still occur with increasing intra-abdominal pressure as the strength of plastic adhesive is less than that of fascial sutures [21–23].

Many advances have taken place in the management of the open abdomen as it has become more customary in the treatment of the critically ill. Better-defined criteria that include patients with massive solid organ injury, bowel edema, abdominal wall resection, and multiple planned relaparotomies (“second looks”) have come to the forefront.

While there is no accepted gold standard for management of the open abdomen, the improvements in trauma care have led to a dramatic rise in the incidence of these cases that have made establishing defined guidelines and algorithms a compelling endeavor. The optimal temporary closure approach provides protection of the intraperitoneal contents, prevents evisceration, preserves fascia, minimizes damage to the viscera by desiccation, quantifies third space fluid losses, permits selective tamponade, minimizes the loss of domain, reduces infection risk, and keeps the patient dry until definitive closure.

Many options are available for management of the abdomen that will not close or that should not be closed. Open abdomen management has proven benefits. Its disadvantages and pitfalls are being resolved through the development of modern principles and techniques. Application of these principles is highly recommended for clinicians taking care of these desperately ill patients.