When approaching a patient with a hostile abdomen, the surgeon must consider several factors. Some questions lead to additional questions and most answers are unfortunately multifactorial thus leading to the apprehension even the most skilled surgeon experiences [3]. Technical considerations, dealt with throughout this book, must be scrutinized. What surgical technique(s) should be employed in approaching and repairing massive abdominal defects? What type of mesh should be utilized? How should the mesh be placed and secured? Few would argue with the concept that the best offense is a strong defense, encompassing preoperative objective markers of physiologic as well as nutritional optimization , but this is only a small portion of the issue at hand. Paramount to the discussion involves the issue of timing. The timing of intervention is not as simple as asking, “How long should we wait until we think it is the optimal time to operate”? One must take into account management of previous or concurrent sepsis, control of pre-existing medical illness, as well as prepare for the probability of operating in a contaminated field, as described in other chapters throughout this book.

Multiple factors influence the answers to these important questions. Special attention must be paid to the patient’s anatomy, physiology, and religious beliefs. Additionally, of particular importance but seldomly discussed in the literature, is the overall coping capacity of the patient and the surgeon, and expectation from the surgery.

Abdominal reconstructive procedures in the patient with a hostile abdomen should not be contemplated prior to the patient’s condition is optimized. For the purposes of this chapter, we assume that patients have overcome the acute phase of their injury/illness and have entered a convalescent phase. In the ideal circumstance, which rarely exists, physiologic and nutritional optimization will have been achieved and well documented. The technical approach and required intervention required will be tailored to each patient individually and definitive management should be postponed pending correction of acute issues as they develop [4, 5]. Additionally, one should not overlook or underestimate the importance of the patient’s psychological state prior to any contemplated surgical intervention. Patients with a hostile abdomen have frequently undergone numerous operative procedures—some successful, others failed. Most have had multiple extended hospital stays, many with prolonged ICU care. Many patients have complex emotional, psychological, social, and financial needs. Anxiety, depression, and chronic narcotic dependence are common and should be addressed with a multidisciplinary approach preoperatively [5]. Furthermore, the patient must have reasonable expectations for the desired outcome. In addition to the “informed consent” discussion focusing on the risk/benefit and possible complications, a preoperative conversation that focuses on likelihood of attaining the desired outcome as well as a clear understanding of all possible outcomes and their implications, both positive and negative, must be entertained.

Three scenarios are presented below, each a short case report describing patients with a hostile abdomen.

A 41-year-old man has survived intra-abdominal sepsis after a catastrophic traumatic event that led to right hip disarticulation and open abdomen management. His abdomen would best be described as hostile with a significant loss of anterior abdominal wall domain noted with a previous skin graft littered with multiple stomas and fistulas that drain a moderate amount of succus entericus. Management to date has focused mainly on collection and diversion of the fistula output via individually tailored stoma bags (Fig. 10.2a). Although sepsis has been controlled recently and his electrolyte and fluid levels have been normalized, he has dealt with multiple nutritional deficiencies of trace elements, proteins, and fatty acids and with multiple bouts of line sepsis. He remains total parenteral nutrition (TPN) dependent and is unable to eat other than for comfort as his multiple fistulas render him functionally with a short-gut syndrome. He resides in an extended care facility and has been out of work for almost a year and wishes to be “put together.”

A 45-year-old morbidly obese woman has a large abdominal wall defect after open abdomen management for trauma. The defect measures 30 cm by 20 cm in greatest dimensions and is noted to consist of a well-healed skin graft loosely veiling her abdominal viscera. She flinches at the sight of her peristalsing bowel and stated she has had recurring episodes of severe depression as she can no longer work or exercise and has “no social life” due to lack of self-confidence. The patient is currently under the care of a psychiatrist and on multiple antidepressant medications as well as chronic opioids. The patient reiterates she sees little hope for a “normal life” unless she was to undergo abdominal reconstruction.

A 58-year-old man has a colostomy for 6 months after catastrophic intra-abdominal sepsis . His previous surgeon attempted to reverse the colostomy originally created to manage complicated diverticulitis but his postoperative period was complicated by an anastomotic leak with intra-abdominal sepsis. Management included multiple abdominal washouts, open abdomen management with fecal diversion via end colostomy. The surgeon was unable to close the patient’s fascia primarily but was able to re-approximate skin over a vicryl mesh. The patient is noted with a large abdominal incisional hernia with a left lower quadrant colostomy. The patient states he cannot work do to recurrent abdominal pain at the hernia site and states he has increasing marital problems due to his displeasure with his physical appearance and concern for malodor. The patient is requesting hernia repair with simultaneous colostomy reversal.

Most surgeons who deal with complex abdominal defects have seen patients similar to the scenarios previously presented. Most fistulas, especially high-output fistulas, will require surgical treatment. Often the patient will have nutritional deficiencies and require treatment similar to a patient with short-gut syndrome [6]. These patients require continuous meticulous attention, both as inpatient and as outpatient, to avoid sepsis (such as catheter-related sepsis in patients on TPN), electrolyte and fluid disturbances, and malnutrition [7–16].

The timing of surgery for ECF is controversial and will be addressed separately on Chaps. 7 and 9; but, for the most part, it depends on the timing of diagnosis, anatomy, and clinical presentation. Other factors affect the decision to operate on patients with enterocutaneous fistulas and complex abdominal wall defects and include etiology of ECFs; early identification of ECFs; achievement of sepsis control; nutritional status; anatomy of ECF; status of local wound; and associated comorbidities and their resolution.

The three scenarios differ clinically but share a commonality; they have survived a hard fought battle to reach their current place in their journey through life and desire an additional chance to regain their perception of normalcy. Under these circumstances, it is understood how an individual could “forget” the bad times and wish to “move on.” Thus, most of them do not focus on the weeks or months in the surgical intensive care unit (ICU); the multiple trips to the operating room, and painful dressing changes. They do not focus on the loss of dignity and autonomy but rather focus on the definitive procedure to be “fixed.” However, the decision to operate is not an easy one. Surgical reconstruction of the hostile abdomen is a technically demanding procedure associated with considerable morbidity. Studies from specialized centers have reported surgical site infection in more than 30% of cases, mortality up to 5%, and fistula and hernia recurrence of 11% and 29%, respectively [17]. It is essential that prior to surgical intervention that the patient has physically and psychologically recovered from the period of the acute illness [18]. Patients should be free of sepsis, adequately nourished, and the abdomen should be soft and supple. Additionally, a significant period of time from the previous operation must have elapsed to allow neoperitonealization of the previously obliterated peritoneal cavity. This may take more than 6 months and prior to this time, a solid block of granulation tissue covers the viscera rendering them indistinguishable from one another [19].

With few exceptions, there are no published reports or definitive recommendations with regard to optimal timing of intervention. Additionally, no predictive index or score delineating success/failure exists and no strategy has been tested in large-scale, randomized clinical trials. In general, the adage that it is “impossible to undertake reconstructive surgery for an enterocutaneous fistula too late; only too early” holds true [15].

While most surgeons agree, delaying surgical intervention on the hostile abdomen for as long as possible and perhaps indefinitely is the safest course of action for the patient, the deleterious impact of the open abdomen on the quality of life of both the patient and the family must be considered. It has been well described that early intervention prior to neoperitonealization increases the risk of inadvertent enterotomy. Studies have reported enterotomy may complicate more than 50% of cases in which 4 or more previous laparotomies were performed and has been predictive of postoperative intensive care unit admission, urgent reoperation, and acute intestinal failure [20, 21]. On the contrary, excessive delay in definitive repair will result in loss of abdominal domain subsequently increasing the difficulty of the abdominal wall reconstruction as well as a higher rate of incisional hernia occurrence [22, 23].

The limited available evidence suggests that when sepsis is controlled, nutritional status is optimized, and anatomy is defined, the surgeon may decide to operate on the hostile abdomen attempting to resect fistulas, reverse ostomies, and reconstruct the abdominal wall [24]. Additionally, the incorporation of a multidisciplinary team including expert nutritional and psychological support provides a strong foundation prior to the monumental task of entering the hostile abdomen. In all cases, employing a strategy that promotes open communication between the patient, family, and the team delineating the possible outcomes and complications as well as expectations of the team and the patient/family is the best approach.

In our practice, we explain to each patient and family, with the utmost clarity, that three main outcomes are possible with surgery: