International Journal of Surgery 12 (2014) 1105e1114

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International Journal of Surgery

journal homepage: www.journal-surgery.net

Original research

Systematic review and evidence based recommendations for the use

of Negative Pressure Wound Therapy in the open abdomen
A. Bruhin a, F. Ferreira b, M. Chariker c, J. Smith d, *, N. Runkel e, f
a

Department of Trauma and Visceral Surgery, Luzern, Switzerland

Hospital Pedro Hispano, Matosinhos-Porto, Portugal
c
Aesthetic Plastic Surgery Institute, Louisville, KY, USA
d
Smith & Nephew, Hull, UK
e
Department of General Surgery, Black Forest Hospital, Villingen-Schwenningen, Germany
f
University of Freiburg, Germany
b

h i g h l i g h t s

NPWT is a widely adopted method of managing the OA but has a weak evidence base.

We present the rst evidence-based recommendations to describe the use of NPWT in OA.

Recommendations divided by grade of open abdomen.

Published literature analysed to compare NPWT with other methods of TAC.

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 12 June 2014
Received in revised form
11 August 2014
Accepted 19 August 2014
Available online 28 August 2014

Introduction: Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open
abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to
develop evidence-based recommendations describing the use of NPWT in the open abdomen. Methods:
A systematic review was carried out to investigate the efcacy of a range of Temporary Abdominal
Closure methods including variants of NPWT. Evidence-based recommendations were developed by an
International Expert Panel and graded according to the quality of supporting evidence. Results: Pooled
results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits
in the open abdomen. This increased to 82% by the addition of a dynamic closure method. Slightly lower
rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients
with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT
with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent
and seemed to be related to the underlying medical condition rather than being inuenced by the choice
of dressing, Treatment goals for open abdomen were dened prior to developing eleven specic
evidence-based recommendations suitable for different stages and grades of open abdomen. Discussion
and conclusion: The most efcient temporary abdominal closure techniques are NPWT kits with or
without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a
complex treatment pathway for the individual patient.
2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Keywords:
Negative Pressure Wound Therapy (NPWT)
Open abdomen
Temporary abdominal closure
Evidence-based recommendations
Systematic review

1. Introduction
Maintaining an open abdomen by means of temporary
abdominal closure (TAC) is a valuable surgical technique in the

management of a wide range of complex abdominal injuries and

conditions including trauma, damage control, sepsis and relaparotomy [1]. There is a great degree of heterogeneity in the
patient population and the surgical methods applied regarding
method of TAC, timing and method of closure. Over the last decade,
Negative Pressure Wound Therapy (NPWT) has been recognised as
a valid method of TAC [2,3]. Although evidence for NPWT is

* Corresponding author. 101 Hessle Road, Hull HU32BN, UK.

E-mail address: jennifer.smith@smith-nephew.com (J. Smith).
http://dx.doi.org/10.1016/j.ijsu.2014.08.396
1743-9191/ 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

2.1. Systematic review

Abbreviations
NPWT
OA
TAC
ACS
EL
STSG

Negative Pressure Wound Therapy

open abdomen
temporary abdominal closure
abdominal compartment syndrome
level of evidence
split thickness skin grafts

emerging at an increasing rate, a consensus on how and when to

use NPWT on the open abdomen is lacking.
The international NPWT Expert Panel, 22 expert surgeons from
different surgical disciplines, was established in 2009 and has
previously published evidence-based recommendations for the use
of NPWT in acute and chronic wound management [4e6]. A systematic review was carried out to evaluate the following research
question: for patients requiring open abdomen therapy, will
treatment with NPWT improve fascial closure rates, mortality and
stula rates compared with other methods of temporary abdominal
closure. Result from the systematic review was used to create
evidence-based recommendations relating to the use of NPWT in
open abdomen.

1.1. Classication of the open abdomen (OA)

Reporting of clinical outcomes in OA often takes no account of
the heterogeneity of the patient populations included within in rck
dividual studies. A classication system was proposed in Bjo
et al. (2009) [7] (Table 1). The classication system recognizes that
within the umbrella clinical indication of OA there exists several
well-dened sub-indications and wound characteristics (such as
intra-abdominal adhesion, infection and stula) each with their
own clinical challenges and prognoses. The absence of wound
classication in the majority of published literature to date, lessens
the ability to understand and contextualize the published literature
in relation to real-life clinical scenarios.
The aim of the present study was to develop evidence-based
recommendations relevant to different grades of OA to clarify the
treatment goals, likelihood of complications, and treatment protocols which may be most appropriate.

2. Methods
This study adopted a combination of a formal evidence-based
medicine activity (systematic literature review) with a formal
consensus development program.

Table 1
rck et al., 2009 [7].
Classication of the open abdomen (OA). modied from Bjo
Grade

Description

1a
1b
2a
2b
3
4 without
stula
4 with stula

without adherence between bowel and abdominal wall or xity

Contaminated OA without adherence/xity
Clean OA developing adherence/xity
Contaminated OA developing adherence/xity
OA complicated by stula formation
Frozen OA with adherent/xed bowel; unable to close surgically;
without stula
Frozen OA with adherent/xed bowel; unable to close surgically;
with stula

A series of systematic searches were carried out according to the

PRISMA guidelines [8]. Searches were limited to studies published
after 1996 (when modern formats of NPWT became commercially
available). PubMed was searched using the following terms to
describe the open abdomen: [(open abdomen OR abdominal
compartment syndrome OR laparotomy) NOT review AND [one of
the following]: (Negative Pressure Wound Therapy OR NPWT OR
Vacuum assisted OR VAC OR vac pack OR vacuum pack) NOT
review]; (bogota bag OR silo) NOT gastroschisis; (wittmann OR
articial burr). These searches were evaluated separately.
Searches were updated in July 2013. Studies reporting patients
requiring open abdomen therapy for any duration and for any
aetiology were included. Individual literature searches identied
studies reporting outcomes on specic interventions. All papers
reporting the intervention under evaluation were included
regardless of the quality or level of the study design. Duplicates
were removed. Papers reporting paediatric patients, in vivo studies
and case series of fewer than 6 patients were excluded. Opinion
pieces or reviews containing no original data were excluded. Papers
describing clinical interventions other than those under investigation were excluded (labelled irrelevant clinical area; Table 2).
Finally, papers reporting major modications to the generally
accepted application techniques of the interventions under analysis
were excluded. All remaining studies were reviewed. Follow up
beyond fascial closure was not tracked. Papers were supplemented
from review of bibliographies of the included papers if they were
deemed relevant and had not already been identied. A post hoc
modication to the search strategy was to divide the NPWT papers
into different specic NPWT methods. This was due to a realisation
that the precise methods employed appeared to have an impact on
outcomes. Thus papers where NPWT was applied along with a
method of sequential closure, and home-made vac-pack style
NPWT methods were considered separately from commercially
available kits. The decision was made to evaluate these data separately. Raw data was extracted from all the papers where possible
(see Supplementary material) and organized in excel (MS ofce).
Where individual data points were missing, the corresponding
author of the paper was contacted by email. No additional data was
retrieved using this method. The main outcomes under investigation were rates of fascial closure, mortality and stula and were
expressed as a weighted mean (percentage) in order to minimise
bias towards the larger studies. In some cases specic data points
(in particular relating to mortality) were inferred from the rate of
surviving patients and similarly the number of fascial closures was
occasionally inferred from reporting of the planned ventral hernia
rate in the surviving population. The rate of fascial closure and
stula rate was therefore calculated on an intent-to-treat basis and
not as a percentage of survivors as commonly reported in the
identied papers. Only the abstracts were reviewed for studies in
languages other than English and data was included where available. No formal analysis of study bias of individual study design was
carried out because of the very high proportion of non comparative
studies identied (no randomization or concealment, high risk of
selective reporting in the majority of papers, little prospective
reporting of outcomes assessment etc). A high risk of bias was
assumed throughout. In order to evaluate whether outcomes
differed according to aetiology, studies were broadly divided according to the presence or absence of sepsis into groups composed
of non-septic abdominal aetiologies (ACS, trauma, abdominal aortic
aneurism etc), septic aetiologies (diverticulitis, peritonitis,
pancreatitis, contaminated abdomens and perforations) and papers
where these aetiologies were mixed. A minimum of 3 data sets

A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

1107

Table 2
Systematic review ow chart. Studies identied from the systematic review were reviewed manually. Those meeting the exclusion criteria were removed. Numbers of papers
include those where the abstract only was reviewed (in parentheses). The NPWT systematic search identied papers describing basic NPWT as well as NPWT sequential
closure. The papers describing sequential closure were separated from the papers describing basic NPWT.
NPWT kits

Vac-pack

NPWT sequential closure

Bogota Bag

Articial Burr

Papers identied (systematic review)

Papers identied from other sources

170
3

31
2

21
0

Reason for Exclusion

2
12
6
11
30
16
24
15
3

0
1
5
3
0
3
5
8
0

0
0
0
1
6
1
1
4
0

8 (1)
8 (1)

8 (1)
8 (1)

Duplicates
In vivo studies
Paediatric
Major technical modication
Irrelevant clinical area
Reviews/comments/letters
Case studies (n < 6)
No relevant outcomes/not available
Paper not available

Papers with relevant data

Papers reviewed

54 (7)
29a,b (5)

13b (5)

12a (0)

a
One paper [40] contained data relevant to both standard NPWT and NPWT Sequential closure and is counted in both columns. For full data extraction please refer to
supplemental digital content 1.
b
One paper [10] contained information about NPWT kit and vac-pack and is counted in both columns.

were required within each category for pooling to be considered

appropriate.
2.2. Development of recommendations
The recommendations presented in this paper were determined
over a period of 2 years in a series of meetings between the NPWTExpert Panel (NPWT-EP) members and a broader discussion in an
international congress where feedback from clinical users was
sought.
Recommendations were developed according to a modication
of the SIGN (Scottish Intercollegiate Guidelines Network) classication system [9] (modication described in legend of Table 3).
Table 3 describes the classication of the levels of evidence used
(L1e4) and the corresponding strength of recommendation that
can be made from each evidence level (Grade AeD). The expert
panel members were conscious of the potentials of fatal misuse of
NPWT in OA and thus have included some concerns of caution and
two non-evidence-based recommendations based on good practice
points (GPP) after extensive discussion within the panel and with a
broader group of wound experts.
3. Relative efcacy of different TAC methods
The systematic review revealed an evidence base rich in noncomparative retrospective studies but with a comparative lack of
good quality randomized studies. Nevertheless, the number of
papers reporting relevant outcomes was high and warranted

further evaluation. The number of relevant papers identied for

each TAC method is shown in Table 2. Rates of fascial closure,
mortality and stulisation are shown in Table 4.
The highest rates of primary fascial closure were reported
following use of commercially available NPWT kits in combination
with a dynamic closure technique e.g. mesh-mediated traction,
dynamic retention sutures or ABRA. These techniques all involve
attachment of a medical device to the fascial edges and sequential
narrowing of the wound opening through incremental approximation of the fascial edges. In a non-septic population this treatment resulted in a pooled intent-to-treat closure rate of 81%
followed by NPWT kits alone (72%), articial Burr (Wittmann
patch) (68%), home-made NPWT (vac-pack) (58%). This is
consistent with another systematic review [2]. There was insufcient data presented on non-septic patients treated with the Bogota
Bag to pool results.
It was hypothesized that rates of fascial closure would be lower
for open abdomen patients with septic aetiologies than with nonseptic aetiologies and this was true in all categories where sufcient data was available for analysis. Addition of a method of dynamic closure along with an NPWT kit resulted in the highest
reported fascial closure rates (74.6%) followed by NPWT kits alone
(48%), vac-pack (35%) and Bogota Bag (27%). There were insufcient
numbers of septic patients treated with the Articial Burr (Wittmann Patch) to calculate pooled fascial closure rates. NPWT,
especially in conjunction with a method of dynamic closure appears to be the most suitable TAC method currently available in the

Table 3A
Translation of Levels of evidence to graded Recommendations. Adapted from the SIGN method of classication [9]. Modication was made by using specic terminology to
clarify the strength of each evidence-based recommendation (Must for grade A, Should for grade B, May for Grade C).
Recommendation
Grade Terminology Description
A

Must

Should

May

D
GPP

Possible
e

At least one meta-analysis, systematic review, or RCT rated as 1, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1, directly applicable to the target population, and demonstrating overall consistency of
results
A body of evidence including studies rated as 2, directly applicable to the target population, and demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 1 or 1
A body of evidence including studies rated as 2, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2
Evidence level 3 or 4; or extrapolated evidence from studies rated as 2
Good practice point. A basic requirement of application consistent with manufacturers instructions and in agreement with the NPWT-EP.

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A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

Table 3B
Evidence Level. Adapted from the SIGN method of classication (9).
Evidence level
Level Description
1 High quality meta-analyses, systematic reviews of RCTs, or RCTs with a
very low risk of bias
1
Well-conducted meta-analyses, systematic reviews, or RCTs with a low
risk of bias
1
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2 High quality systematic reviews of case control or cohort or studies. High
quality case control or cohort studies with a very low risk of confounding
or bias and a high probability that the relationship is causal
2
Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2
Case control or cohort studies with a high risk of confounding or bias and
a signicant risk that the relationship is not causal
3
Non-analytic studies, e.g. case reports, case series, in vivo or in vitro
studies
4
Expert opinion

septic or contaminated abdomen. These conclusions are consistent

with another systematic review [2].
Mortality in the open abdomen is greatly inuenced by the
underlying medical condition. Mortality rates calculated from the
pooled data ranged from 12% to 25% in a non-septic population vs.
22%e40% in septic or mixed populations. Studies using vac-pack to
manage patients with septic aetiologies reported the highest
overall mortality rate, at 40%. This was higher than the mortality
rate for patients treated with NPWT kits at 26%. It was not possible
in the systematic review to match the studies in terms of the injury
severity or other such scores relevant to risk of mortality and so no
rm conclusions can be drawn with regard to the inuence of TAC
method on mortality however, this difference has also been
demonstrated in a study comparing a new variant of NPWT kit
based dressing with vac-pack [10] and remains to be more thoroughly investigated.
One past controversy, whether NPWT may be linked to the
development of enterocutaneous stula [11,12], has now largely
been disproved [13]. Carlson et al. (2013) [13] investigated the
incidence of stula formation in NPWT treated open abdomen
wounds compared with other methods of TAC in a nation-wide
audit carried out in the UK over an 18 month period. No signicant difference in the incidence of stula formation was observed
regardless of the method of TAC employed. In another study [14]
signicantly fewer stulae were observed in patients treated with
NPWT compared with other methods of TAC. The data shown in
Table 4 is consistent with these studies and does not show any
evidence of a relationship between use of NPWT and stula
formation.

Table 5
Treatment Goals for application of NPWT. Although NPWT is a treatment that
operates simultaneously through multiple actions, in order that specic recommendations could be made and voted on, a single overarching treatment goal was
selected as part of the consensus process. Closed circles indicate the dominant goal
and open circles indicate secondary goals within each indication. A cross indicates a
goal which is NOT desired. Blank space indicates the goal is not relevant.
Goals

Grade
4 with
1 2 3a 4
without stulaa
stulaa

Protect bowel from damagea

To splint the wounda
To minimize formation of adhesions
To support the early physiological
recovery of the patient
Management To manage wound uid and oedemaa
To prevent wound deterioration
Manage and divert the stula efuent
Closure
To provide temporary wound cover
until fascial closure is possible or
desired
Extend the window for primary
fascial closure
Encourage the healing of the closed
incision after denitive closure.
To promote granulation tissue
formation to create good wound bed
for grafting
Protection

B
B
B
B

B B B
B B B
B B
B

B
B

B B B B
B B B B
C
C B B

B
C

B C
B B
x

x x

Denotes general treatment goals which relate to all grades of OA.

It is likely that a higher degree of stulisation occurs in septic OA

compared with non-septic OA (12.1% vs. 3.1% respectively for NPWT
kit treated patients) (Table 4). It is uncertain whether the higher
incidence of stula in the septic group results directly from the
presence of severe prolonged intra-abdominal sepsis or is related to
the longer duration of TAC observed under septic conditions. Fistulisation rates are known to increase with duration of open
abdomen [15]and therefore it may be appropriate to label septic OA
wounds, especially those undergoing protracted TAC as high-risk
for stula development. Insufcient information was available on
Bogota bag or Wittmann Patch in septic patients.
4. Evidence based recommendations
4.1. General treatment goals and recommendations
NPWT acts via several different modes of action. Specically,
NPWT can address several issues relating to the protection of the
open abdomen (e.g. against external damage and bacterial ingress),
management of the open abdomen (e.g. uid handling pain management, mobilization, skin protection) and closure of the open
abdomen (e.g. extending the window for primary fascial closure or
improving graft take in abdomens closed by STSG). These specic

Table 4
Systematic review e relative safety and efcacy of different methods of TAC.
Device/method

Condition of abdomen

# Patients (#studies)

Fascial closure %

Mortality (%)

Fistula (%)

References

NPWT kit

Non-septica
Septic/mixed
Non-septica
Septic/mixed
Non-septica
Septic/mixed
Non-septic
Mixed

337
941
188
270
551
238
155
396

72.0
47.5
81.9
74.6
57.7
35.2
68.0
26.6

16.5
26.0
24.6
22.8
16.9
40.5
13.7
30.3

3.7
12.1
6.7
5.5
6.0
eb
3.1
6.6

[10,18,26,64,77e79]
[12e14,22,25,40,58,68e70,80e91]
[31e33,35,92]
[30,34,36e40]
[10,19,20,93e97]
[98e102]
[43,44,79,97,103,104,105]
[22,106e112]

NPWT kit sequential closure

Vac-pack
Articial Burr
Bogota Bagc
a

(7)
(22)
(5)
(7)
(8)
(5)
(7)
(8)

Representing studies composed almost entirely of either non-septic.

Insufcient data in this subset to calculate.
While papers could be divided into non-septic and septic cohorts, this would leave insufcient data points (<3) for analysis. Data for Bogota bag were therefore assessed as
a mixed aetiology.
b
c

A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

Table 6
General recommendations for the use of NPWT in OA. The numbered recommendations correspond with the order in the main body of the text.
Goal

Recommendation and grade (AeD/GPP)

To protect
1. An interface layer must be used to
bowel from
protect exposed organs and (where
damage
possible) avoid adhesions between
the bowel and abdominal wall
To splint the 2. Use of a specialised open abdomen
wound
foam-based dressing should be used
To manage
3. NPWT may be used to manage
wound uid
abdominal wound uid
Treatment
4. Continuous NPWT settings of up
variables
to 80 mmHg are recommended

References and
evidence level (1
e4)
GPP

B
C
D

L2:
L3:
L2:
L3:
L3:

[10,21]
[17,18]
[22]
[23,29,64]
[28]

actions can all be converted into specic treatment goals (Table 5).
Some treatment goals are relevant to the OA in general and some
rck et al. [7]).
are relevant only to specic grades (as classied by Bjo
This is described in more detail below where evidence-based recommendations have been developed that are relevant regardless of
the grade of OA (Table 6).
4.1.1. General recommendation 1: An interface layer must be used
to protect exposed organs and to avoid adhesions between the
bowel and abdominal wall. Table 6; GPP
A key treatment goal for the use of NPWT in grade 1 and 2 OA is
to prevent deterioration of the wound to the next grade. To minimise the development of abdominal xity (progression to Grade 4)
use of a large, fenestrated non-adherent interface layer reduces
adhesions between the exposed bowel and the inside of the
abdominal wall thus retaining the option of fascial closure. All
commercial NPWT devices contain a dedicated interface layer as
part of the kit. Application of a non-adherent interface layer can
reduce the risk of stula formation (progression to grade 3) [16] as
prevention of adhesions leads to lower risk of bowel damage. The
interface layer should be placed as widely as possible inside the
abdomen: in grade 1 and 2 OA, laterally into the paracolic gutters,
cranially onto the diaphragm after taking down the falciforme
ligament and caudally into the pelvic cavity.
Caution: Failure to apply a non-adherent interface layer may
expose the patient to a signicant risk of stula formation as a
result of potential damage to the bowel during dressing changes.
4.1.2. General recommendation 2: Use of a specialised open
abdomen foam-based dressing kit should be used. Table 6; Grade B
All commercial kits contain polyurethane foam in a variety of
formats. This foam acts in a similar way in all commercial products
and is able to compress under negative pressure which may lead to
improved preservation of abdominal domain by mediating constant medial traction of the abdominal wall [17,18]. Without this
splinting effect, lateral retraction of the abdominal wall over a
period of days, may result in loss of domain, preventing reapproximation of the fascial edges. Surgical towels used as the
wound ller in the vac-pac technique (an off-the-shelf method of
NPWT) [19,20] are known not to shrink under compression and
therefore have a limited ability to splint the wound. This may have
an impact on the ability to achieve early fascial closure in damage
control indications: Hatch et al. (2011) (EL2) reported that use of
foam-based NPWT, but not vac-pack based NPWT was an independent predictor of early fascial closure [21]. Furthermore prospective comparative studies comparing a commercial kit with vacpack demonstrates signicant increase in fascial closure rate with
the commercial product [10] (EL2). This is in addition to the analysis

1109

shown in Table 5 which demonstrates improved outcomes in

studies reporting commercial systems as opposed to vac-pack
dressings (described above). To date no studies have compared
the clinical efcacy of different commercial NPWT open abdomen
specic products. There are no publications regarding the use of
gauze as a wound ller for TAC.
Caution: Preserve the integrity of the surrounding skin by accurate placement of the wound ller within the wound rather than
on top of the skin.
4.1.3. General recommendation 3: NPWT may be used to manage
abdominal wound uid. Table 6; Grade C
One major advantage of NPWT over the other TAC techniques is
its ability to actively drain uid as a result of the application of
negative pressure (Table 5) reducing the pooling of sterile or
contaminated uid within the abdominal cavity. Signicantly more
uid can be evacuated from OA wounds treated with NPWT than
with passive drainage (such as the Bogota bag) with volumes of
around 800ml being frequently reported [22,23]. The better uid
handling provided by the NPWT dressing may reduce the frequency of analgesia-requiring wound dressing changes and can
prevent complications secondary to lying in wet beds.
Another potential benet of NPWT is that all evacuated uid is
directed into a waste canister preventing contamination of the
ward and personal alike. Furthermore, the diversion of uid protects the surrounding skin from maceration and frequent dressing
changes. Measurement of the uid in the canister is easily carried
out and may contribute to more rapid uid replacement and
nutritional support. Quick identication of the uid quality such as
blood or feces may be observed at an early stage through frequent
observation of the content of the canister.
In an animal model of open abdomen, NPWT was shown to
signicantly reduce intestinal oedema compared with passive
drainage [23]. Although this has not been conrmed clinically in
the open abdomen, an NPWT-mediated reduction in oedema has
been observed in other indications [24].
Maintaining the abdomen in a moist environment as a result of
the NPWT top layer adhesive lm also prevents uncontrolled
evaporative uid loss, secondary external bacterial contamination
and reduces heat loss.
4.1.4. General recommendation 4: Continuous NPWT settings of up
to 80 mmHg are recommended. Table 6; Grade D
Negative pressures from 75 mmHg [25] to 175 mmHg [26]
have been reported. No studies have investigated the most appropriate level of negative pressure to apply to an open abdomen and
insufcient data was provided in the reviewed studies to compare
outcomes dependent on the level of pressure used (data not
shown). Continuous pressure levels of less than e 80 mmHg are
recommended and as low as 50 mmHg in vulnerable patients (e.g.
those with previous anastomosis or dilated small bowel). The
prevalent untested assumption is that the higher the pressure
levels, the higher the potential for damage to the underlying organs, hence the tendency towards caution and towards lower
pressures in this series of recommendations. In an animal study
(L3) higher levels of NPWT resulted in a measurable reduction in
bowel blood ow which correlated with increasing negative pressure [27]. Although the clinical impact of this observation is uncertain, this is a potential area for improvement. When choosing
the level of pressure, a balance must be found between potential
damage to the underlying organs (supporting lower pressures) and
the effective removal of uid (pressures up to 120 mmHg lead to
greater uid drainage) [28]. Adoption of a new commercially
available NPWT device resulted in the delivery of no pressure to the
bowel surface, despite effective removal of uid [29].

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A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

Intermittent pressure (where pressure settings uctuate between on and off) or variable pressure (where pressure setting
uctuate between high and low) are not recommended. Under
these pressure regimes, the ability of NPWT to splint the open
abdomen wound is severely compromised.

4.2. Grade-specic goals, recommendations and cautions

In addition to the general treatment goals described above,
some treatment goals are only relevant to specic grades of OA as
rck et al. [7] (Table 5). These goals are used as the
dened by Bjo
basis for the specic recommendations described in this section
shown in Table 7.

Table 7
Grade-specic recommendations for use of NPWT in Grade 1e4 open abdomen.
OA
Goal
grade

Recommendation and grade Supporting

(AeD)
reference and
evidence level (1
e4)

experienced
To provide temporary 5. In
hands NPWT should
wound cover until
be used as a rst line
fascial closure is
therapy in Grade 1A
possible or desired
and 2A open
abdomen where
there is an option
for delayed primary
closure, including
following decompression of ACS
6. Application of a
sequential dynamic
closure technique,
along with NPWT to
counteract retraction and facilitate
delayed primary
closure should be
considered
7.Always use a nonTo extend the
window for primary adherent interface
layer to protect
fascial closure
To prevent wound
exposed organs and to
progression
prevent progression to
grade 3 or 4.
Encourage healing of 8. Application of incithe closed incision
sional NPWT on the
closed incision to
facilitate healing
should be
considered
Grade To manage and divert 9. NPWT may be used
3
the stula efuent
to manage output of
an enteroatmospheric stula.
10. It is possible to use
Grade To promote
NPWT to
4
granulation tissue
encourage granuformation to create
lation tissue forgood wound bed for
mation to support
grafting
split closure by
split thickness skin
graft.
To splint the wound 11. NPWT should be
used to enhance
split skin graft take
at the abdomen.
Grade
1
and
2

L2: [21,22]
L3: [23]

L1: [40]
L2: [31,36]
L3: [30e35,38]

GPP L2: [36]

L3: [18,26,42]
L4: [41]

L1:[51,52]a
L2: [45,46,48],
[53,54]a
L3: [47,49]

L3: [56e59,67]

L3:
[12,19,68,69,78,91]

L1a: [71e73]
L2a: [74e76]
L3: [57,59,65]

a
Denotes studies carried out on other indications (not open abdomen) where
relevant data have been extrapolated for relevance in the open abdomen.
GPP good practice point. The numbered recommendations correspond with the
order in the main body of the text.

4.2.1. Grade 1 and 2 open abdomen wounds (with no or minimal

adherence)
4.2.1.1. Grade 1 and 2 e recommendation 5: In experienced hands
NPWT should be used as a rst line therapy in Grade 1 and 2 open
abdomen where there is an option for delayed primary closure,
including following decompression of ACS; Table 7; Grade B.
The key treatment goal in the treatment of Grade 1 and 2 OA
wounds is to provide temporary wound cover until fascial closure is
possible or desired (Table 5). In wounds which can be expected to
achieve fascial closure relatively easily (such as some ACS and
trauma-derived open abdomen cases), use of NPWT is recommended over the other available methods of TAC for a number of
reasons. Firstly, unlike Wittmann patch and other zipper or mesh
based techniques NPWT is a suture-less technology and its application does not damage the fascial tissue [8]. Secondly, unlike the
Bogota Bag bag approach, NPWT helps to prevent loss of abdominal
domain in addition to providing active uid drainage. Finally, in the
period immediately following laparotomy, use of NPWT can
signicantly normalize serum lactates [22] and systemic inammatory mediators [23] compared with passive drainage (such as
Bogota Bag) indicating that application of NPWT can inuence a
patients' physiological stability.
In grade 1A abdominal wounds (trauma, ACS, post-abdominal
surgery) where early and uncomplicated fascial closure is expected, the fewer repeat laparotomies the better before fascial
closure. In a EL2 study, patients closed at the rst repeat laparotomy
were more likely to have been managed with NPWT compared with
those requiring more prolonged NPWT (73% vs. 49% p < 0.001) and
NPWT was an independent predictor for this early closure [21]. One
EL3 study reported that 43% of trauma OA patients required only a
single episode of NPWT prior to fascial closure [19]. In a retrospective comparative study signicantly fewer dressing changes
were required in the NPWT group compared with other methods of
TAC prior to fascial closure [14].

4.2.1.2. Grade 1 and 2 e recommendation 6: Application of a

sequential dynamic closure technique, along with NPWT to counteract
retraction and facilitate delayed primary closure should be considered. Table 7; Grade B. It is important that fascial closure be tension
free in order to avoid ischaemia and subsequent necrosis of the
fascial and to reduce the risk of ACS from developing. Sequential
dynamic primary closure involves applying small amounts of tension to the fascia sequentially, at each repeat laparotomy in order to
eventually reach the goal of primary fascial closure. The development of zips, clips, resorbable meshes, and Velcro analogues (e.g.
the Wittmann patch), human acellular dermal matrix, or the use of
various dynamic suturing techniques facilitate this staged approach
and can be initiated when patient is stabilised and intra-abdominal
infection/injury is under control. The rate of approximation is
dependent on abdominal tension, which is a function of oedema
resolution and abdominal tension.
Application of dynamic suturing [30,31] mesh [32e37] and the
ABRA system [38,39] in conjunction with NPWT results in an
overall fascial closure rate of 79% (Table 4), the highest closure rate
of any closure technique assessed in the systematic review. Pliakos
et al. E(L1) [40], Burlew et al. (EL2) [31] and Rasilainen et al. (L2)
[36] independently reported statistically signicantly improved
rates of fascial closure in patients who received NPWT in addition
to dynamic closure compared with NPWT alone. Rasilainen et al.
[36] reported that patients treated with NPWT plus mesh were able
to be closed up to 3 weeks following the initial surgery. This means
that adoption of sequential closure as an adjunct to NPWT may
increase the window during which fascial closure is possible.

A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

4.2.1.3. Grade 1 and 2 e recommendation 7: Always use a nonadherent interface layer to protect exposed organs and to prevent
progression to grade 3 or 4. Table 7; GPP. When maintaining an open
abdomen, there is a window of opportunity within which to achieve primary fascial closure, usually dened as 7e10 days from the
original laparotomy, before xity develops and the wound progresses into a Grade 4 abdomen. Treatment of the open abdomen is
bi-phasic: typically, grade 1A wounds would require a minimal
period of TAC leading to early fascial closure (within 7 days).
However in many remaining patients and for a variety of reasons,
early fascial closure is not possible. An additional treatment goal for
the use of NPWT is to extend the window for primary fascial closure
[41] (EL4) (Table 5). This would allow more time for resuscitation
and sufcient recovery whilst preserving the option of fascial
closure. Miller et al. (2004) [18] reported almost 50% of their successful primary fascial closures were performed late i.e. after 9
days of NPWT and as late as 21 days. Other studies have reported
fascial closure with NPWT as late as 18 [26] and 49 days [42]. Late
closures have however also been reported for both Wittmann patch
(42 days) [43] and to a lesser extent with Bogota Bag (30 days) [44].
In the absence of comparative studies it is impossible to state
denitively which TAC method most efciently extends the window for fascial closure in patients unsuitable for early fascial
closure. In addition, the interface may serve as an enhanced
drainage system for uid that may otherwise be retained in the
deep abdominal cavity.
4.2.1.4. Grade 1 and 2 e recommendation 8: Application of incisional
NPWT on the closed incision to facilitate healing should be considered.
Table 7; Grade B. Once closure of the fascia and skin have been
achieved it is possible to use NPWT to support healing of the closed
laparotomy incision and prevent complications. A signicant
reduction in wound complications including wound dehiscence
was observed compared with standard gauze dressings in a
comparative (EL2) study [45]. NPWT has also been used to support
healing of high risk abdominal incisions in procedures where the
abdomen is closed at the index operation [46e48]. In two
comparative retrospective studies (EL2), a signicant reduction in
wound complications overall and in particular a reduced incidence
of infection was observed in wounds treated with incisional NPWT
compared with standard dressings [46,48]. The splinting effect of
the application of NPWT is also believed to aid patient mobility by
supporting the wound as reported in a level 3 study [49]. Early
patient mobility is thought to be important in reducing duration of
ICU stay and improving long-term outcomes [50].
The use of NPWT on closed incisions has been demonstrated to
good effect in other clinical indications. Data from these studies can
be extrapolated to provide further support of its likely efcacy in
healing of at risk laparotomy incisions. Several comparative
studies (EL1 [51,52] and EL2 [53,54]) have been reported in other
indications which principally show the reduction in complications
that can be achieved through application of NPWT to a closed
incision [55].
There are cases when only segments of the abdominal wall can
be closed and others remain dehiscent. In these situations, NPWT is
a good choice of wound ller in analogy to other wounds.
4.2.2. Grade 3 open abdomen wounds (complicated by stula
formation)
Intestinal stulae result from anastomotic leakage, traumatized
or ischaemic bowel, pressure ulceration or rupture in case of distal
intestinal obstruction. A stula opening directly from the bowel
into an OA is known as an entero-atmospheric stula (EAF). If a
stula appears before abdominal xation occurs, it is classed as a
Grade 3 OA. Surgical repair, by suturing although possible, is rarely

1111

successful. Segmental resection can be attempted although care

must be taken with the site of anastomosis during all subsequent
procedures. If this is not possible then a controlled stoma can be
considered as described below.
4.2.2.1. Grade 3 e recommendation 9: NPWT may be used to manage
output of an entero-atmospheric stula. Table 7; grade D. No existing
TAC methods are ideal in the treatment of a grade 3 OA (with stula) although NPWT has been used to good effect in these wounds
and may be described as the most best option currently available if
used with caution. The principle goal in grade 3 wounds when
applying NPWT is to manage and divert the stula output to prevent the spread of intra-abdominal sepsis [56e58] (Table 5). NPWT
can be used to manage the output and divert it away from the open
abdominal wound [56e59]. Depending on the viscosity of the stula output, pooling beneath the foam may occur. To prevent this,
provision of a conduit from the source of the efuent through the
dressing to the canister either by means of an ostomy bag or a drain
can be considered [57]. Use of NPWT can splint the wound to
anchor any drainage tubes. This ensures that the drain remains very
close to the mouth of the stula to maximise uid removal but is
prevented from damaging the bowel as a result of becoming
dislodged.
Visible stulae can be managed by means of a oating stoma
which involves isolating the stula with an ostomy bag. NPWT is
often the only method available to achieve a secure bag adhesion
particularly in the mobile patient and may simultaneously be used
to manage the adjacent wound [57].
Remote stulae are not suitable for direct stomal isolation. One
option is to convert a remote entero-atmospheric stula into an
entero-cutaneous stula by performing a separate incision and
drainage. In abdominal wounds which have not yet developed
xity, this may allow progression of the wound as described in
grade 1 and 2 aiming at early primary fascial closure. An alternative
strategy is to treat the entire wound with NPWT, allowing the
wound to granulate and contract. This leads to closure of the tract
but results in a grade 4 OA wound which is incapable of fascial
closure as well as being both time-consuming and costly. In these
wounds, spontaneous closure of the entero-atmospheric stula has
been observed in 55% [58], and 8% [60] of wounds as well as being
observed in a handful of case studies [59,61e64]. Once output is
controlled, and a granulating bed has been achieved, it may be
possible to make conservative efforts to close by skin grafting
[57,59,65]. This may reduce the risk of further entero-atmospheric
stula observed as a result of prolonged maintenance of an open
abdomen [12,66].
NPWT may also protect skin from the stula output thus helping
to preserve the integrity of peri-wound skin [56,67].
4.2.3. Grade 4 open abdomen wounds (frozen abdomen)
Prolonged inability to close the fascia will ultimately result in a
xed abdomen in which granulation tissue forms over the surface
and in amongst the internal organs, classed as a Grade 4 OA. Once
the abdominal wound has progressed to Grade 4, adhesions between the bowel loops and the xity of the intestines to the
abdominal wall are so advanced, that attempts to release the adhesions by physical manipulation is highly likely to result in major
lesions. It is therefore important to stop releasing the strong adhesions not to risk bowel injuries. At this stage, removal of all nonabsorbable meshes is mandatory. Remaining available closure options involve a planned ventral hernia and include skin closure,
secondary healing or split skin grafting. The fascia and skin should
be closed as far as possible to minimize the remaining surface
requiring a skin graft. The planned ventral hernia approach

1112

A. Bruhin et al. / International Journal of Surgery 12 (2014) 1105e1114

requires denite operative reconstruction some months later and is

usually deferred for a minimum of 6 months.
4.2.3.1. Grade 4 e recommendation 10: It is possible to use NPWT to
encourage granulation tissue formation to support split closure by
split thickness skin graft. Table 7; Grade D. The principle goal for
application of NPWT in grade 4 OA, now that fascial closure is no
longer possible, is to promote granulation tissue formation to
create a suitable surface for rapid grafting (Table 5). The degree of
graft-take depends on the quality of the recipient wound bed, thus
once granulation tissue has covered the surface of the exposed
organs and a frozen abdominal wound is present, NPWT may be
used to encourage rapid granulation tissue growth [68,69]. Under
these circumstances the degree of adherence between the viscera
and the abdominal wall is too far advanced to permit application of
the non-adherent interface layer. Physical manipulation of the adhesions should be avoided at this stage. The granulation tissue and
underlying organs are delicate and must be protected by the use of
a wound contact layer (e.g. non-adherent silicon adherent layer)
placed between the NPWT wound ller and the wound bed. The
wound contact layer prevents growth of newly formed granulation
tissue into the foam NPWT wound ller which may result in
damage to the underlying tissue when removed, during dressing
changes [68]. The promotion of granulation tissue by NPWT is
widely reported in other indications however direct extrapolation
of this data to the specic indication of open abdomen is not
appropriate given the additional risks posed by having vulnerable
bowel structures in close proximity to the granulating bed. A correlation has been reported between the number of re-explorations
after initiation of NPWT and stula formation [70]. This reinforces
the need for extreme caution during dressing changes and the use
of the interface layer to minimize the impact of dressing changes.
4.2.3.2. Grade 4 e recommendation 11: NPWT should be used to
enhance split skin graft take in the abdomen. Table 7; Grade B.
Once granulation tissue has formed over the surface of the bowel,
leaving an abdominal wound that can't be closed by primary fascial
closure, a skin graft can be performed as soon as clinically appropriate (e.g. on resolution of sepsis). In large defects, split skin graft is
the only option to rapidly close the abdomen. NPWT is shown to
promote a signicantly higher degree of graft take in a variety of
non-abdominal indications in several EL1 RCTs [71e73] and EL2
comparative cohort studies [74e76] The use of NPWT to bolster
STSG has been systematically reviewed in more detail elsewhere
[4]. Several case reports (EL3) of using NPWT to bolster skin grafts
on open abdomen wounds have been reported [57,59,65] suggesting its positive effect in these wounds also. There is a high
degree of relevance when comparing data from other indications
and the use of NPWT to bolster a skin graft in a planned ventral
hernia approach to abdominal closure. The results of the EL1 and
EL2 studies can therefore be extrapolated to support the use of
NPWT to bolster skin grafts in the open abdomen.

recommendations presented here, specify the use of NPWT

throughout the treatment pathway of the open abdomen and
provide greater clarity around the appropriate use of NPWT.
Ethical approval
N/A (no clinical results presented).
Funding
S&N provided funding for travel and accommodation for all
face-to-face expert panel meetings, provided support regarding the
published literature in NPWT, provided support during the drafting
of treatment goals and recommendations (author JS) and provided
medical writing services in preparation of this manuscript (JS). The
recommendations reect the independent and unbiased views of
the panel and the consensus derived during the project and the
content of the manuscript has not been unfairly inuenced by
Smith & Nephew.
The NPWT-Expert Panel was supported by Smith & Nephew.
Author contribution
Authors AB, FF, MC and NR participated in all expert panel
meetings relating to this project, identied, discussed and agreed
all recommendations through a combination of clinical knowledge
and review of available evidence. All authors contributed to
manuscript preparation. Author JS provided methodological
expertise and conducted the systematic review and provided
editorial assistance with regard to manuscript preparation.
Contributors: Thanks to the wider NPWT expert Panel (NPWTEP): J.M. Francos Martnez, S. Vig, C. Caravaggi, C. Dowsett, P. Rome,
L. Berg, H. Birke-Sorensen, M. Depoorter, R. Dunn, F. Duteille, G.
Grudzien, D. Hudson, S. Ichioka, R. Ingemansson, S. Jeffery, E. Krug,
C. Lee, M.Malmsjo for their contribution to the early discussions
which formed the original basis for this manuscript. Thanks to
Hussein Dharma and Alan Rossington who provided support with
relation to data management and analysis.
Conict of interest
Authors MC, AB, FF and NR have undertaken consultancy work
for Smith & Nephew (S&N) in the area of NPWT and have received
honoraria from S&N. MC has served as a fact witness in legal testimony for S&N. Author JS is an employee of S&N.
Disclaimer
These materials are provided for educational use only and do
not imply that the authors have endorsed Smith & Nephew's
products in any way or that the techniques being used are endorsed
or recommended by Smith & Nephew.

5. Conclusion
Appendix A. Supplementary material
In the clinical setting, each patient with open abdomen is a
major challenge for the physicians and nurses. As each case is
complex and unique, NPWT is a key technique to provide an individualised approach because NPWT can provide different actions at
different stages of treatment: e.g. wound and uid management,
facilitating primary fascial closure and splinting of skin grafts. A
systematic review of the literature has demonstrated greater rate of
primary fascial closure in patients treated with NPWT, especially
where NPWT is used along-side a dynamic closure technique,
compared with other methods of TAC. Evidence-based

Supplementary material related to this article can be found at

http://dx.doi.org/10.1016/j.ijsu.2014.08.396.
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