Hernia

https://doi.org/10.1007/s10029-018-1818-9

REVIEW

EHS clinical guidelines on the management of the abdominal wall

in the context of the open or burst abdomen
M. López‑Cano1 · J. M. García‑Alamino2 · S. A. Antoniou3 · D. Bennet4 · U. A. Dietz5 · F. Ferreira6,7 · R. H. Fortelny8,9 ·
P. Hernandez‑Granados10 · M. Miserez11 · A. Montgomery12 · S. Morales‑Conde13 · F. Muysoms14 · J. A. Pereira15 ·
R. Schwab16 · N. Slater17 · A. Vanlander18 · G. H. Van Ramshorst19 · F. Berrevoet18

Received: 13 May 2018 / Accepted: 21 August 2018

© Springer-Verlag France SAS, part of Springer Nature 2018

Abstract
Purpose  To provide guidelines for all surgical specialists who deal with the open abdomen (OA) or the burst abdomen (BA)
in adult patients both on the methods used to close the musculofascial layers of the abdominal wall, and regarding possible
materials to be used.
Methods  The guidelines were developed using the Grading of Recommendations Assessment, Development and Evalua-
tion (GRADE) approach including publications up to January 2017. When RCTs were available, outcomes of interest were
quantitatively synthesized by means of a conventional meta-analysis. When only observational studies were available, a
meta-analysis of proportions was done. The guidelines were written using the AGREE II instrument.
Results  For many of the Key Questions that were researched, there were no high quality studies available. While some strong
recommendations could be made according to GRADE, the guidelines also contain good practice statements and clinical
expertise guidance which are distinct from recommendations that have been formally categorized using GRADE.
Recommendations  When considering the OA, dynamic closure techniques should be prioritized over the use of static closure
techniques (strong recommendation). However, for techniques including suture closure, mesh reinforcement, component
separation techniques and skin grafting, only clinical expertise guidance was provided. Considering the BA, a clinical
expertise guidance statement was advised for dynamic closure techniques. Additionally, a clinical expertise guidance state-
ment concerning suture closure and a good practice statement concerning mesh reinforcement during fascial closure were
proposed. The role of advanced techniques such as component separation or relaxing incisions is questioned. In addition,
the role of the abdominal girdle seems limited to very selected patients.

Keywords  Guidelines · Open abdomen · Burst abdomen · Evisceration · Fascial dehiscence · Hernia · Abdominal wall
closure

Introduction intended to optimize abdominal wall patient care based on a

Over the last years, the European Hernia Society (EHS)
has decided to produce different clinical practice guidelines
(CPG) alone [1–3] or in collaboration with other societies
[4]. According to the definition of CPG [5], the aim of the
EHS is to generate statements that include recommendations
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s1002​9-018-1818-9) contains
supplementary material, which is available to authorized users.
* M. López‑Cano
mlpezcano@gmail.com
Extended author information available on the last page of the article
systematic review of the evidence and an assessment of the
benefits and harms of alternative care options.
The so-called open abdomen (OA) and the burst abdomen
(BA) are well-known clinical conditions. In clinical prac-
tice, both nosological entities are characterized by a complex
spectrum of symptoms, which in many cases pose a great
challenge for surgical repair and management of the abdomi-
nal wall [6]. The OA leaves a laparotomy incision without
closure and is an intended surgical treatment option when
required to support the patient generally, control abdomi-
nal sepsis (if any), minimize damage to the abdominal con-
tents while the abdomen is open, minimize adherence of
the abdominal contents to the anterior abdominal wall and

13
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 Hernia
get the abdominal wall closed. The BA (also referred to as
‘evisceration’ or ‘fascial dehiscence’) is an unintended acute
wound failure at the level of the fascia and is a postoperative
complication after primary closure of a laparotomy incision.
There should be a focus on avoiding a BA and implementa-
tion of guidelines and recommendations can play a critical
role in this [2]. In both conditions, the final common chal-
lenge is the closure of the abdominal wall [6]. However,
reported procedures to close the abdominal wall in the OA or
BA context are very heterogeneous with different techniques
and modifications [6–9].
The EHS decided to embark on a CPG development pro-
ject for management of the abdominal wall closure in the
context of an OA or BA due to the lack of relevant summa-
rized evidence and recommendations. The aim is to provide
guidelines for all surgical specialists who deal with the OA
or BA in adult patients both on the methods used available
to close the musculofascial layers of the abdominal wall,
and regarding possible materials to be used. Other aspects
in connection with complications associated with the OA
or BA, such as the management of intraabdominal hyper-
tension, abdominal compartment syndrome or enteroatmos-
pheric fistulas are not included in this analysis.
Methods
The project was approved during the EHS board meeting in
March 2016, and Manuel López-Cano (EHS quality advi-
sory board) and Frederik Berrevoet (EHS advisory board
of science) were designated to coordinate the project. A
steering committee was appointed, which consisted of four
members of the EHS board and one methodological assistant
(JGA). The guideline development protocol was defined by
the coordinators between April and May 2016. The steer-
ing committee and the coordinators met in Barcelona on
June 30th and July 1th 2016, and the protocol was presented
and 12 Key Questions (KQ) were formulated and translated
into patient-intervention-comparison-outcome (PICO) for-
mats, six in relation to the OA and six to the BA (Annex
I Supplementary material). During this first meeting, the
steering committee and coordinators attended a seminar on
the methodologic aspects of Grading of Recommendations
Assessment, Development and Evaluation Working Group
(GRADE) [10]. The GRADE system was used to guide the
methodology and structure during production of the guide-
lines. The steering committee and coordinators composed
the rest of the guideline development group (GDG), which
included general, trauma and abdominal wall surgeons com-
prising 18 members from nine European countries.
On December 15th and 16th 2016, a second meeting with
the entire group was organized in Brussels. A second semi-
nar on the basis of GRADE methodology was presented.
13
Additionally, the KQ were further discussed and approved
and the GDG agreed and it was decided that all types of
techniques in connection with abdominal wall closure in the
OA or BA were to be explored with the exception of the zip-
per technique (i.e., closing the skin or the fascial layer only
by approximating it by the positioning of a common zipper,
sutured to the two edges of the surgical incision) and the use
of towel clips (i.e., positioned to maintain the skin closed).
These techniques were considered historical. The OA due to
the loss of abdominal wall tissue as the result of oncologic
resections or traumatic injuries was excluded.
For each KQ at least two GDG members were assigned
as investigators and specific search terms were formulated
and search strategies designed (Annex II Supplementary
material). In January 2017, the bibliographic search was
independently done for each KQ by two members of the
GDG (ML-C and SA), together with a clinical librarian.
The search included the databases of MEDLINE (PubMed),
SCOPUS, WEB OF SCIENCE (WOS) and EMBASE with
no date or language restrictions. We selected randomized
controlled trials (RCTs) and non-randomized studies (NRS
observational) (i.e., Cross-sectional studies, Case–control
studies, Cohort studies and Case Series). We excluded case
reports and expert opinions. In a first-level screening, the
search results for each key question in the form of titles and
abstracts were distributed to the subgroups. A second-level
screening was conducted by at least two members of each
subgroup including the full texts of articles retrieved at the
first-level screening. Relevant articles entered the quality
assessment and grading of evidence process (Annex II Sup-
plementary material). These articles were assessed for their
quality by at least two members of each subgroup using
GRADE methodology. Factors influencing the quality of
evidence across studies for different outcomes according to
the GRADE approach include study design, risk of bias,
inconsistency across studies (unexplained heterogeneity
of results), indirectness of results (direct results consist of
research that directly compares the interventions which we
are interested in), imprecision (when studies include rela-
tively few patients and few events), publication bias (sys-
tematic underestimation or overestimation of the underlying
beneficial or harmful effect due to the selective publication
of studies), and effect size. The quality of evidence was rated
as high, moderate, low, and very low (high: very confident
that the true effect lies close to that of the estimate of the
effect; moderate: moderately confident in the effect estimate,
that is, the true effect is likely to be close to the estimate of
the effect, but there is a possibility that it is substantially
different; low: confidence in the effect estimate is limited,
that is, the true effect may be substantially different from the
estimate of the effect; very low: very little confidence in the
effect estimate, that is, the true effect is likely to be substan-
tially different from the estimate of the effect).
Hernia
Data retrieved (outcomes of interest) from relevant
articles were Definitive (primary) Fascial Closure (fascia-
to-fascia closure of the abdominal defect with or without
prosthetic repair material within the initial hospitalization)
[11], Mortality (30 days), Re-burst abdomen, Surgical Site
Occurrences (SSO) [surgical site infections—SSI—follow-
ing CDC definitions [12] + hematoma + seroma], Incisional
hernia, Fistula formation and OA complexity grade [13].
Age, sex distribution and the indications related to the OA
or type of patients related to a BA were retrieved too. Qual-
ity data and outcomes of interest were collected in a specific
template and were uploaded in a specifically designed online
generated database accessible by all members of the GDG.
Study data of acceptable quality articles were tabulated in
GRADE summary of findings tables (SoF tables) and for
this the online GRADEpro/GDT software (gradepro.org)
was used. The data collected were presented as the mean
age with 95% confidence interval (CI), the proportion of
males and the reason for the OA or BA type of patients.
When RCTs were available, outcomes of interest were quan-
titatively synthesized for each KQ by means of a conven-
tional meta-analysis [random effects model, data presented
as risk ratios (RR) with 95% CI] using the Review Manager
5.3 software (Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2013). When only NRS obser-
vational studies were available, a meta-analysis of propor-
tions using OpenMetaAnalyst [14] was done to calculate an
overall weighted proportion of each outcome of interest (the
data are presented as the overall proportion with 95% CI).
Heterogeneity was assessed using I2 statistics.
Based on the previous assessments, each subgroup pro-
posed a recommendation for each key question. In line with
the GRADE methodology [15, 16], recommendations were
classified as STRONG (the recommended course of action
would be chosen for treating all or almost all patients and
indicates to clinicians that the recommendation is appropri-
ate for all or almost all individuals. Strong recommendations
represent candidates for quality of care criteria or perfor-
mance indicators) or WEAK (indicates that for the majority
of patients the suggested course of action would be chosen,
but for an appreciable minority it would not). With weak
recommendations, clinicians should recognize that different
choices will be appropriate for individual patients. Weak
recommendations should not be used as a basis for stand-
ards of practice—other than to aid shared decision-making.
If there was no evidence on a key question, or if it was of
inadequate quality, no recommendation was made. The
guideline also contains good practice statements and clini-
cal expertise guidance, which are distinct from recommen-
dations that have been formally categorized using GRADE.
Good practice statements represent common-sense prac-
tice, are supported by indirect evidence, and are associated
with assumed large net benefit. Clinical expertise guidance
provides direction in areas for which there is either no pub-
lished evidence or insufficient evidence to justify a formal
recommendation. These do not have the force of either rec-
ommendations that have been categorized using GRADE or
good practice statements [17].
In a third consensus meeting in Barcelona on March 30th
and 31th 2017, the GDG reviewed, modified, and refined
the recommendations. Final approval was made via email
and by teleconference with all members of the GDG. The
guideline was presented in a session of the European Hernia
Society Congress on May 27th 2017 in Vienna. The guide-
line manuscript was drafted by the coordinators in August
and September 2017 and sent for review and agreement by
all co-authors. Prior to submission it was peer-reviewed by
three external reviewers, who assessed its methodological
soundness according to the AGREE II instrument [18].
Results
What is the optimal fascia closure in an OA?
Analysis, sub-analysis, tables and figures related to the OA
KQ are shown in Annex III Supplementary material. Table 1
provides the recommendations related to each key question.
Here we describe six KQ recommendations in greater detail.
Key Question 1 Patients with non-adherent bowel loops/
abdominal wall (Grade 1) without intestinal fistula and when
definitive (primary) fascial closure is likely within the initial
hospitalization period. Should we use continuous or inter-
rupted sutures in an OA closure?
Recommendations: as a clinical expertise
guidance continuous monofilament sutures
following a SL:WL ratio of at least 4:1
should be used.
Comments Three observational studies fulfilled the cri-
teria and were included in the meta-analysis [19–21]. The
indications for OA were septic and non-septic conditions,
the proportion of males was greater than 50% in all studies
and the mean age was 73 years (95% CI 71.3–74.6 years).
There were no outcome data available on mortality, SSO,
BA or fistula formation. The only outcome data that could be
retrieved were for the development of an incisional hernia.
The pooled proportion of incisional hernia related to the
use of continuous sutures was 16.2% (95% CI 4.2–33.9%)
(I 2 = 72.1) and related to the use of interrupted suture
was 18.3% (95% CI 0.1–63.7%) (I2 = 87.1). According to
13
 Table 1  Summary of recommendations
Key questions for open abdomen Recommendation SR WR EQ GPS CEG

13
1. Patients with non-adherent bowel loops/abdominal wall (Grade 1) without Continuous monofilament sutures following a SW/WL ratio over 4 should be – – Very low – Yes
intestinal fistula and when definitive (primary) fascial closure is likely used
within the initial hospitalization period. Should we use continuous or inter-
rupted sutures in an OA closure?
2. Patients with non-adherent or adherent bowel loops/abdominal wall (Grade Mesh augmentation should be advised. SSO could increase. Final decision – Very low – Yes
1 or 2) without intestinal fistula and when definitive (primary) fascial clo- should be balanced by the surgeon in charge
sure is likely within the initial hospitalization period. Should mesh versus
no mesh be used for reinforcement during fascial closure in an OA?
3. Patients with non-adherent or adherent bowel loops/abdominal wall Unresolved issue. Separate the components of the abdominal wall in any way – – Very low – Yes
(Grade 1 or 2) and without intestinal fistula and stomas and when definitive must be carefully balanced in each case
(primary) fascial closure is likely within the initial hospitalization period.
Should component separation (CS)/relaxing incisions/fascio-myoplasties be
done previous to fascial closure in an OA?
4. Patients with non-adherent or adherent bowel loops/abdominal wall (Grade If a static technique is being considered, NPWT should be used and mesh – Yes Low – –
1 or 2) and without intestinal fistula and when definitive (primary) fascial bridging (inlay) should be avoided
closure is likely within the initial hospitalization period. Should temporary
static closure techniques be used in an OA?
5. Patients with non-adherent or adherent bowel loops/abdominal wall (Grade Dynamic closure techniques should be used where possible Yes – Low – –
1 or 2) and without intestinal fistula and when definitive (primary) fascial
closure is likely within the initial hospitalization period. Should temporary
dynamic closure techniques be used in an OA?
6. Should skin grafts be used for abdominal wall closure to cover a fixed These kinds of patient should be closed using a skin graft. In an OA without – – Very low – Yes
abdomen (Grade 3) if skin or muscle flaps are not available/possible in an a fixed abdomen should be avoided as a first option
OA?
Key question for burst abdomen
 1 Patients with non-adherent or adherent bowel loops/abdominal wall Continuous monofilament sutures following a SW/WL ratio over 4 should be – – Very low – Yes
without intestinal fistula and when definitive (primary) fascial closure is used
possible within the initial hospitalization period. Should we use continu-
ous or interrupted sutures in a burst abdomen closure?
 2 Patients with non-adherent or adherent bowel loops/abdominal wall and Mesh augmentation should be advised. SSO could increase. Final decision – – Very low Yes -
without intestinal fistula and when definitive (primary) fascial closure is should be balanced by the surgeon in charge
possible. Should mesh be used for reinforcement during fascial closure in
a BA?
 3. Patients with non-adherent or adherent bowel loops/abdominal wall and Unresolved issue. Separate the components of the abdominal wall in any way – – Very low - Yes
without intestinal fistula. Should component separation/relaxing incisions must be carefully balanced in each case
be done to obtain fascial closure in a BA?
 4. Patients with adherent bowel loops/abdominal wall and without intestinal Unresolved issue. NPWT should probably be the first option when static – – Very low - yes
fistula and when definitive (primary) fascial closure is likely impossible measures are chosen
within the initial hospitalization period. Should temporary static closure
techniques be used in a BA?
 5. Patients with adherent bowel loops/abdominal wall and without intestinal Unresolved issue. MMFT + NPWT should be used as a first option. No spe- – – Very low – YES
fistula and when definitive (primary) fascial closure is likely within the cific technique can be advised
Hernia

initial hospitalization period. Should temporary dynamic closure tech-

niques be used in a BA?
 Hernia

the statistical analysis, there was no significant difference

SR strong recommendation, WR weak recommendation, EQ evidence quality, GPS good practice statement, CEG clinical expertise guidance, SW/WL suture wound/wound length, SSO surgical
GPS CEG

YES
between either suture techniques with regard to incisional
hernias as their proportion and CIs overlapped. A high level
of heterogeneity was expected to occur as the evidence con-
Very low –

sists of case series only. The GDG members agreed that the
limited number of patients analyzed and the very low quality
WR EQ

of data included was insufficient to make any recommenda-

tion regarding the use of continuous or interrupted sutures.
–

However, and even though there is no definite information

SR

available on how to close the fascia in the context of an

–

OA, the GDG agreed that the pooled results were slightly
in favor of a continuous suture technique in terms of the
reduction in the rate of incisional hernia. On the other hand,
the EHS Guidelines on the closure of abdominal wall inci-
sions [2] recommend the use of continuous suture and sug-
gest slowly absorbable monofilament suture with a SL:WL
Unresolved issue. Only in a very limited number of patients

ratio of at least 4:1 for the closure of a laparotomy incision.

The GDG agreed if it is possible to close the fascia in an
OA, it is logical to close following the recommendations
established in the literature. The GDG agreed that a clinical
expert guidance statement that continuous slowly absorbable
monofilament suture following a SL:WL ratio of at least
site occurrence, NPWT negative pressure wound therapy, MMFT mesh-mediated fascial traction, OA open abdomen

4:1 should be used in an OA closure in patients with non-

adherent bowel loops/abdominal wall and without intestinal
fistula and when definitive (primary) fascial closure is likely
within the initial hospitalization period.
Remarks Analyzed studies were performed in high-
Recommendation

income countries.
Key Question 2 Patients with non-adherent or adherent
bowel loops/abdominal wall (Grade 1 or 2) without intestinal
fistula and when definitive (primary) fascial closure is likely
within the initial hospitalization period. Should mesh versus
possible within the initial hospitalization period. Should abdominal girdle

no mesh be used for reinforcement during fascial closure in

(indications not to primary close, “conservative” management) be used in
 6. Patients with non-adherent or adherent bowel loops/abdominal wall and
without intestinal fistula and when definitive (primary fascial) closure is

an OA?

Recommendations: as a clinical expertise guidance,

mesh implantation should be advised during
definitive (primary) fascial closure. The use of
mesh is associated with an increased incidence of
SSO. The final decision to use a mesh, the type of
mesh and the mesh position should be balanced by
the surgeon in charge.
Key questions for open abdomen

a burst abdomen?

Comments Four observational studies fulfilled the criteria

Table 1  (continued)

and were included in the proportional meta-analysis [22–25].

The indications for an OA were septic and non-septic condi-
tions and trauma, the proportion of males was greater than
50% in half of the studies and the mean age was 47 years

13
 Hernia

(95% CI 43.2–50.7 years). Outcome data for the develop- lack of substantial evidence in these areas. The GDG identi-
ment of an incisional hernia, SSO, fistula formation and fied SSO as a potential cause of harm associated with the use
mortality could be retrieved. A proportional meta-analysis of mesh reinforcement. Consequently, the monitoring and
using there data was done for each of these outcomes. For tight control of SSO is recommended for patients in whom
the development of an incisional hernia, data were included mesh is used.
from four observational studies [22–25] (98 patients); for Key Question 3 Patients with non-adherent or adherent
fascial closure + mesh reinforcement, the pooled propor- bowel loops/abdominal wall (Grade 1 or 2) and without
tion for the development of an incisional hernia was 19.4% intestinal fistula and stomas and when definitive (primary)
(95% CI 4.4–41.4%) (I2 = 82.8). The heterogeneity was high, fascial closure is likely within the initial hospitalization
which was anticipated as the data were available from case period. Should component separation (CS)/relaxing inci-
series only. For SSO, data were included from four observa- sions/fascio-myoplasties be done prior to fascial closure in
tional studies [22–25] (98 patients). In this case, the pooled an OA?
proportion was 31.9% (95% CI 10.2–59.0%) (I2 = 86.6). For
fistula formation, three observational studies were included
Recommendations: The GDG decided to
[22–24] (74 patients); the pooled proportion for fistula for-
mation was 6.6% (95%CI 1.8–14.1) (I2 = 14.9). For mor- consider KQ 3 as an unresolved issue and
tality, data from three observational studies was included
decided not to formulate a recommendation on
[22–24] (74 patients) and the pooled proportion was 6.4%
(95% CI 0.29–28.9%) (I2 = 85.3). the use of component separation/relaxing
There are little data in the literature reporting the inci-
incisions/myoplasties for the purpose of fascial
dence of incisional hernia development after fascial closure
in an OA context. However, it is estimated that this incidence closure in an OA. As a clinical expertise
can be 35% at 2 years and 66% at 5 years [20]. Conversely,
guidance, separation of the components of the
reports of intestinal fistula in the context of an OA range
from 5 to 75% [26]. The OA has been associated with mor- abdominal wall in any way must be carefully and
tality rates of > 30% [27].
Very low quality evidence shows that the use of mesh
judiciously evaluated to avoid potential harm for
reinforcement during fascial closure in an OA has pooled future abdominal wall surgical treatment.
proportional benefits in terms of the reduction in incisional
hernia formation (19.4%), a low incidence of fistulas (6.6%)
and a low incidence of mortality (6.4%). The pooled pro-
Comments Two observational studies related to a com-
portion of SSO is rather high (31.9%). In the interpretation
ponent separation (CS) technique [28, 29] and two obser-
of the results, the GDG carefully considered the low level
vational studies related to fascio-myoplasty techniques [30,
of evidence related to the analysis of observational studies.
31] fulfilled the criteria to be included with a very limited
However, taking into account the high incidence of inci-
number of patients included. This limited and very low
sional hernia development, fistula formation and mortality in
quality evidence was considered as insufficient to make any
association with an OA described in the literature, the GDG
recommendation regarding the use of component separa-
agreed that the pooled figures for the use of mesh reinforce-
tion/relaxing incisions/fascio-myoplasties for the purpose of
ment are significantly lower, and therefore the GDG agreed
fascial closure in an OA. As a clinical expertise guidance,
as a clinical expert guidance that mesh reinforcement be per-
the GDG agreed that the use of techniques that separate the
formed during fascial closure in an OA. However, the GDG
components of the abdominal wall in any way must be care-
acknowledged that this suggestion for intervention, with
fully and judiciously balanced, since the abdominal wall of
the same strength for all surgical patients, would potentially
patients with an OA, in terms of rigidity and edema, does not
pose cost and feasibility constraints, including diagnostic
present the same characteristics as an abdominal wall of an
implications to identify the most appropriate candidates. In
individual who is going to undergo elective hernia surgery.
addition, the heterogeneity of patients included in the studies
Remarks The GDG agreed that a wrong selection of one
analyzed and the higher pooled proportion of SSO associ-
of these techniques in an OA context may add potential com-
ated with the use of mesh reduced the strength of the guid-
plexity to future hernia repair in the same patient. The GDG
ance. As a result, the GDG agreed that the final decision to
agreed that more data are needed regarding the use of these
use a mesh should be made by the surgeon in charge.
types of techniques.
Remarks Analyzed studies were performed in high-
Key Question 4 Patients with non-adherent or adherent
income countries. No recommendation could be made
bowel loops/abdominal wall (Grade 1 or 2) and without
regarding the type of mesh or the mesh position due to the

13
Hernia
intestinal fistula and when definitive (primary) fascial clo-
sure is likely within the initial hospitalization period. Should
temporary static closure techniques* be used in an OA?
*Bogota bag (plastic silo), Negative Pressure Wound
Therapy (NPWT) (commercial and non-commercial), Mesh
bridging (inlay).
Recommendations: The GDG suggests that NPWT
should be used in an OA as a static closure
technique if a dynamic closure technique is not an
option. (Weak recommendation, low quality of
evidence)
The GDG suggests that mesh bridging (inlay)
should be avoided as a static closure technique in
OA due to the incidence of fistula formation
observed. (Weak recommendation, low quality of
evidence)
Comments Forty studies fulfilled the criteria to be
included regarding NPWT [32–71]. Thirty nine were obser-
vational studies [32–70] and one was a randomized con-
trolled trial (RCT) comparing two NPWT modalities [71].
Eleven studies fulfilled the criteria relating to the use of
mesh bridging (inlay) [22, 72–81], ten were observational
[22, 72–79, 81] and one was a RCT comparing open and
closed abdomen in severe secondary peritonitis [80]. Nine
observational studies fulfilled the criteria relating to the use
of the Bogota bag (plastic silo) [79, 82–89]. Globally, the
indication for an OA was 88% septic and non-septic condi-
tions versus 12% trauma. In 77.5% of studies, the proportion
of males was greater than 50%, and in 7.5% of studies, the
patients’ gender was not available. The overall mean age was
53.9 years (95% CI 53.6–54.2 years).
Regarding fascial closure in relation to the use of NPWT,
data were included from 36 observational studies (2002
patients) and the pooled proportion achieving fascial clo-
sure was 52.1% (95% CI 45.3–58.8%) (I2 = 88.7). Utilizing
data from 37 studies (2081 patients), the pooled proportion
of fistula formation relating to the use of NPWT was 10.6%
(95% CI 8.1–13.6%) (I2 = 73.2). Finally, after including data
from 37 studies (2124 patients), the pooled data indicated
a mortality rate of 26.5% (95% CI 22.3–31.1%) (I2 = 80.1).
When considering the use of mesh bridging techniques
for fascial closure, data were included from four obser-
vational studies (518 patients) and the pooled proportion
achieving fascial closure was 36.9% (95% CI 10.3–69.0%)
(I2 = 97.0). After including data from four studies (240
patients), the pooled proportion of SSO related to mesh
bridging was 28.1% (95% CI 3.1–65.2%) (I2 = 96.1). The
pooled data for fistula formation related to the use of mesh
bridging (10 observational studies, 763 patients) were 12.4%
(95% CI 6.4–20.0%) (I2 = 82.7). When the development of
an incisional hernia following the use of mesh bridging was
looked at (4 observational studies, 215 patients), the pooled
proportion was 67.8% (95% CI 10.1–99.8%) (I2 = 97.7).
Finally, for the mortality rate related to the use of mesh
bridging (10 observational studies, 763 patients), the pooled
proportion was 23.7% (95% CI 16.7–31.6%) (I2 = 74.9).
When considering the use of the Bogota bag (Plastic silo)
for fascial closure, data from seven observational studies
were retrieved (368 patients) and the pooled proportion for
achieving fascial closure was 28.5% (95%CI 13.4–46.7%)
(I2 = 86.2). The pooled data for fistula formation related
to the use of the Bogota bag (8 observational studies, 437
patients) were 10.2% (CI 6.3–15.0%) (I2 = 50.1). Finally, the
pooled data for mortality related to the use of the Bogota
bag (9 observational studies, 475 patients) were 29.2% (95%
CI 18.9–40.9%)(I2 = 84.9). The heterogeneity was again
high, as anticipated when only case series were available
for inclusion of this analysis. Low quality evidence showed
that the use of static closure techniques in an OA was related
to an overall pooled proportion of fascial closure of 33.9%
(95% CI 17.8–52.3%) and fistula formation of 11.9% (95%
CI 8.7–15.7%) and an overall pooled proportion of mortality
of 25.5% (95% CI 22.1–29.1%). The GDG carefully con-
sidered this evidence and the additional subgroup analysis
conducted by the systematic review and concluded the most
effective static closure technique was NPWT (commercial
and non-commercial). The rate of fistula formation was
slightly higher when mesh bridging was employed while
similar fistula formation rates were found for NPWT and
the Bogota bag (plastic silo). The mortality figures relat-
ing to the static measures were similar for the three groups
with figures ranging from 23.7 to 29.2%. These data were
compared with those of two OA registries (“real world evi-
dence”) published so far [7, 8]. Interestingly, the pooled pro-
portion for fascial closure reported in the IROA register [7]
in relation to NPWT (Commercial and non-commercial—
NPWT assisted and Barker vacuum pack) was quite similar
to those obtained in our review, with rates of 60% and 52.1%,
respectively. Similarly, the proportion of fistula formation
related to NPWT was almost the same in the IROA register
[7] as in our review with pooled proportion rates of 11 and
10.6%, respectively. The figures for fascial closure utiliz-
ing the Bogota bag (plastic silo) were different in the IROA
register than in our review with rates of 71.3 and 28.5%
reported. One explanation for this difference is that the
IROA considers skin closure while this review only looked
at fascial closure. Perhaps another reason for the higher rates
13
 Hernia
of fascial closure in the IROA register using the Bogota bag
(plastic silo) is that in the majority of patients, the OA was
traumatic in origin, while in our review, septic patients were
predominant. Fistula formation was similar between IROA
and our review with rates of 7.4 and 10.2%, respectively,
although mortality rates differed, 16.8 vs 29.2%. When con-
sidering the cause of the OA recorded in the EuraHS register
[8] and comparing the overall pooled proportion of fascial
closure using static measures, there was a total overlap
between this register (25.0–36.4%) and our review (33.9%);
the same holds true more or less for fistula formation (18.5
and 11.9%, respectively). No data regarding mesh bridging
were found in the registers. However, the GDG agreed that
there was an association between mesh bridging (inlay) and
fistula formation. Furthermore, the majority of meshes used
in the papers included in our review (81%) were meshes with
a reticular architecture. When considering the indications for
the OA, the IROA register [7] shows figures of 80% of septic
and non-septic conditions and only 20% trauma patients. The
Open Abdomen Route recorded in the EuraHS register [8]
shows figures of 88% of septic and non-septic conditions
and 12% trauma patients. Again, these figures overlap with
the figures in this review, in which 88% were due to septic
and non-septic conditions and 12% were trauma patients. In
view of previous results, the GDG agreed to suggest that if
a dynamic closure technique is not available, NPWT should
be used in OA patients with non-adherent or adherent bowel
loops/abdominal wall (Grade 1 or 2) and without intestinal
fistula and when definitive (primary) fascial closure is likely
within the initial hospitalization period. The GDG suggests
that mesh bridging (inlay) be avoided as a static measure
technique in OA patients due to the observed association
with fistula formation.
Remarks The vast majority of analyzed studies were per-
formed in high-income countries. The GDG agreed that the
data reported here matches the use of static measures in an
OA worldwide (according to registered data). The GDG also
agreed that the heterogeneity of indications in the included
articles represents a considerable patient and treatment
selection bias and may have had a profound effect on the
results (fascial closure, fistula formation and mortality rates).
The GDG concluded that the mortality rates mostly reflect
differences in patient population (patient selection) and to
a lesser extent a direct effect of the applied static measure
technique. The GDG also concluded that mesh bridging
(inlay) itself is associated with an increased risk of fistula
formation due to the potential direct contact of the mesh
material (the majority in this review had a reticular architec-
ture) with the abdominal contents (bowel) and differences in
the protective sheets or omentum used to cover the viscera.
Therefore, the GDG concluded that there was insufficient
evidence to either confirm or reject the assumption that mesh
bridging (inlay) with reticular meshes in the OA increases
13
the risk of fistula formation. However, the GDG strongly
supported the technique that when used, the NPWT sponges
should not be in direct contact with exposed bowel.
Key Question 5 Patients with non-adherent or adherent
bowel loops/abdominal wall (Grade 1 or 2) and without
intestinal fistula and when definitive (primary) fascial clo-
sure is likely within the initial hospitalization period. Should
temporary dynamic closure techniques* be used in an OA?
*ABRA system, Wittmann Patch, ABRA system + Nega-
tive Pressure Wound Therapy (NPWT) or fascial traction
(mesh or other) + NPWT.
Recommendations: Dynamic closure
techniques should be used in patients with
Grade 1 or 2 OA. (Strong recommendation,
low quality of evidence)
The panel recommend the use of dynamic
closure techniques over static closure
techniques (where possible). (Strong
recommendation, low quality of evidence)
Comments Thirty-five studies fulfilled the criteria to be
included in KQ5 [19, 21, 23, 25, 70, 90–119]. Four were
randomized controlled trials (RCT) comparing fascial trac-
tion versus no fascial traction [90–93]. The rest of the studies
found were observational: 4 studies regarding the ABRA
system [94–97], 5 related to the use of the Wittmann patch
[98–102], 2 combining ABRA with NPWT [103, 104],
14 studies combining mesh-mediated fascial traction with
NPWT (MMFT–NPWT) [19, 23, 25, 70, 105–114] and 6
combining other types of fascial traction with NPWT [21,
115–119]. All the data from the RCTs were related to fascial
closure. The observational studies provided data on fascial
closure, fistula formation and mortality rates. Globally for
patients managed with dynamic closure techniques, the indi-
cation for an OA was 66% septic and non-septic conditions
and 34% trauma. In 88% of the studies, the proportion of
males was greater than 50%, and in 12% the patients’ gen-
der was not available. The mean age was 54.9 years (95%
CI 54.2–55.5 years).
The meta-analysis of RCTs comparing fascial traction
versus no fascial traction (148 patients) did not report sig-
nificant results in favor of one method over the other 1.13
RR (95% CI 0.68–1.87) (I2 = 65). The limitations of this
conventional meta-analysis were mainly high heterogeneity,
the small number of studies included and the small number
Hernia
of patients analyzed. The GDG agreed that no conclusion
could be drawn. When the proportional meta-analysis of
dynamic closure techniques was performed, the pooled
proportion achieving fascial closure (1282 patients) was
75.9% (95% CI 63.2–88.5%) (I2 = 96.5), for fistula forma-
tion (1120 patients) the pooled proportion was 4.3% (95%
CI 2.5–6.2%) (I2 = 53.2) and for mortality (1142 patients) it
was 16.3% (95% CI 10.6–21.9%) (I2 = 83.3). The heteroge-
neity was high, which was anticipated as mainly case series
were included. Low quality evidence showed that the use
of dynamic closure techniques in an OA is associated with
high overall fascial closure rates, independent of the method
used, as the pooled proportions for each method overlap
with each other. The pooled proportion for fistula formation
associated with dynamic closure methods is low and again,
similar between the different methods. The pooled mortality
rate associated with dynamic closure techniques was 16.3%.
The data obtained from the proportional meta-analysis were
compared with current register data (“real world evidence”)
[7, 8]. When the IROA register [7] was analyzed, data were
only available on the use of the Wittmann patch, but inter-
estingly these data (42 patients) and our analysis on fascia
closure with this device (188 patients) totally overlapped
(i.e., 65.7 and 64.9%, respectively). However, when fistula
formation associated with the use of the Wittmann patch was
analyzed, the figures were different, with a 2.8% fistula rate
in this analysis and a 17.6% rate in the IROA register. Mor-
tality using the Wittmann patch was again similar, 20.6% in
the IROA and 16.1% in this analysis. A similar comparison
was performed with the OA data recorded in the EuraHS
register [8] and comparable numbers can again be observed;
in the EuraHS register, the pooled proportion of fascial clo-
sure with methods involving fascial traction ranged from
66.7 to 79.7% and in this analysis the pooled proportion
was 75.9%. The rates of fistula formation in the context of
dynamic closure techniques were higher in the OA patients
recorded in the EuraHS register (9.8%) compared to this
analysis (4.3%).
The overall pooled results of static closure techniques
(KQ 4) and the pooled results of the dynamic closure tech-
niques were compared with a clear difference in all out-
come measures in favor of the dynamic closure techniques
(Table 2). In the light of these results, the GDG strongly
Table 2  Pooled results of static versus dynamic closure techniques
for open abdomen
Outcome Static closure techniques Dynamic closure tech-
(KQ4) (overall pooled niques (KQ5) (overall
proportion) (%) pooled proportion) (%)
Fascial closure 33.9 75.9
Fistula formation 11.9 4.3
Mortality 25.5 16.3
recommended that dynamic closure techniques be used in
patients with non-adherent or adherent bowel loops/abdomi-
nal wall (Grade 1 or 2) and without intestinal fistula and
when definitive (primary) fascial closure is likely within
the initial hospitalization period. The GDG concluded that,
given the small differences between different methods in
relation to rates of fascial closure and fistula formation and,
as the data are derived from low quality papers with het-
erogeneous patient populations, the choice of one method
over another will depend on the surgeon in charge and the
resources availability (economics and material). The GDG
agreed to prioritize the use of dynamic closure techniques
over that of static closure techniques (where possible).
Remarks
Analyzed studies were performed in high-income countries.
The GDG noted that the heterogeneity of indications in the
included articles still represented a considerable patient and
treatment selection bias and may therefore have had a pro-
found effect on outcomes (fascial closure, fistula formation
and mortality rates). The differences in mortality rates most
likely reflect differences in patient population (patient selec-
tion) and only to a lesser extent imply a direct effect of the
applied dynamic closure technique. As in the previous KQ,
CDG agreed that the NPWT sponges should not be in direct
contact with exposed bowel.
Key Question 6 Should skin grafts be used for abdominal
wall closure to cover a fixed abdomen (Grade 3) if skin or
muscle flaps are not available/possible in an OA?
Recommendations: As a clinical expertise
guidance this small subgroup of patients with a
fixed abdominal content should be closed using a
skin graft to avoid fistula formation.
The use of a skin graft in an OA situation without
a fixed abdominal content should be avoided as a
first option of treatment.
Comments Only one observational study utilizing skin
grafting fulfilled the criteria to be included [120]. This lim-
ited and very low quality evidence was considered as insuf-
ficient to make any recommendation regarding the use of
skin grafts in a fixed OA. The GDG agreed that in patients
with a fixed abdomen skin grafting would be a safe alterna-
tive to minimize mortality and complications. The incidence
of fistula formation in the context of an uncovered OA has
13
 Hernia
been reported to be up to 75% with a mortality of up to 42%
[26] and in some cases skin grafting may be the only option.
Remarks The GDG agreed that the use of a skin graft in
an OA situation without a fixed abdominal content should
be avoided as first-line treatment. Skin grafts should only be
used if other treatment options to achieve definitive abdomi-
nal closure in the initial hospitalization period are not pos-
sible or if the patient’s condition remains dire for a longer
period of time not allowing for other options.
What is the optimal fascia closure in a BA?
Analysis, sub-analysis, tables and figures related to a BA
KQ are shown in Annex IV Supplementary material. Table 1
provides the recommendations related to each key question.
Here we describe six KQ recommendations in greater detail.
Key Question 1 Patients with non-adherent or adherent
bowel loops/abdominal wall without intestinal fistula and
when definitive (primary) fascial closure is possible. Should
we use continuous or interrupted sutures in a BA closure?
Recommendation: as a clinical expertise guidance
continuous monofilament sutures following a
SL:WL ratio of at least 4:1 should be used to
close a BA
Comments Evaluation of the evidence identified four
observational studies [121–124]. The type of patients asso-
ciated with a BA were septic and non-septic conditions, the
proportion of males was greater than 50% in all studies and
the mean age was 65 years (95%CI 64.4–65.5 years). There
were no data available on mortality rates, SSO, re-burst
abdomen or fistula formation. The only outcome for which
data could be found was the development of an incisional
hernia. Utilizing these data, a proportional meta-analysis
was performed comparing the use of continous and inter-
rupted sutures. The pooled proportion of cases developing
an incisional hernia with continous suture techniques was
33.6% (95% CI 19.3–49.7%) versus 33.6% using interrupted
sutures (95% CI 25.1–42.6%). There was no significant dif-
ference between either suture techniques regarding the
development of an incisional hernia as their proportion and
CIs overlapped. Due to the limited number of patients ana-
lyzed and the very low quality of data analyzed, the evidence
was considered insufficient to make any recommendation
regarding the use of continous or interrupted sutures. The
GDG members agreed not to formulate a recommendation
on this topic in favor of one suture technique over the other.
However, the GDG agreed that in the context of a BA, the
fascial edges may be severely damaged by sutures, local
13
inflammation and tissues weakened by both inflammation
and concomitant infection. Furthermore, it has been shown
that a fascial dehiscence often occurs because the quality of
the suture technique at the time of primary wound closure
was deficient, and consequently the suture-holding capacity
of the normal tissues was exceeded [125, 126]. Therefore,
the suture length (SL) to wound length (WL) ratio achieved
at the time of wound closure is crucial, and the strength of
the sutured wound increases with a higher ratio [127, 128].
As for the OA closure and according to the European Hernia
Society Guidelines on the closure of abdominal wall inci-
sions [2], the GDG agreed to suggest as a clinical expertise
guidance that a continous monofilament suture following
a SL:WL ratio of at least 4:1 be used in a BA closure in
patients with non-adherent or adherent bowel loops/abdomi-
nal wall and without intestinal fistula and when definitive
(primary) fascial closure is possible.
Remark Analyzed studies were performed in high-income
countries.
Key Question 2 Patients with non-adherent or adherent
bowel loops/abdominal wall and without intestinal fistula
and when definitive (primary) fascial closure is possible.
Should mesh be used for reinforcement during fascial clo-
sure in a BA?
Recommendation: as a good practice statement
mesh reinforcement should be used whenever
fascial closure is possible. Mesh is related to an
increased incidence of SSO. The decision to use
a mesh, the type of mesh used and the location of
the mesh should be considered by the surgeon.
Comments Four observational studies fulfilled the cri-
teria and were included in the meta-analysis [129–132].
The baseline type of patients was emergencies and elec-
tive conditions, the proportion of males was greater than
50% in all studies and the mean age was 67.7 years (95%
CI 67.1–68.3 years). There were no data available on the
incidence of a re-BA or fistula formation. Outcome data on
the development of an incisional hernia, rates of SSO and
mortality rates were retrieved.
For the development of an incisional hernia, data were
included from four observational studies (277 patients for
fascial closure only versus 135 for fascial closure + mesh
reinforcement) [129–132]. The pooled proportion of inci-
sional hernia rates occurring after fascial closure only was
32.9% (95% CI 24–42.4%) (I2 = 44.9) compared to 12.5%
for fascial closure + mesh reinforcement (95% CI 4.9–23.1%)
Hernia
(I2 = 61.8). Statistical analysis confirmed that this was a
significant difference in favor of fascial closure with mesh
reinforcement. The heterogeneity was high in both groups,
which was already expected to occur, as only case series
were included. When considering SSO, data were included
from two observational studies (53 patients for fascial clo-
sure and 77 patients for fascial closure + mesh reinforce-
ment) [131, 132]. The analysis showed that the pooled
proportion of SSO was higher in the group with mesh aug-
mentation (48.8%, 95% CI 12.05–86.4%) (I2 = 91.0) than for
fascial closure alone (23.5%, 95% CI 13.3–35.5%) (I2 = 0).
For mortality rates, data were included from three observa-
tional studies (102 patients for fascial closure versus 107 for
fascial closure + mesh reinforcement) [130–132]. The pooled
proportion for the mortality rate for fascial closure alone
was 19.8% (95% CI 7.6–35.8%) (I2 = 70.6) versus 15.4%
in the group with mesh reinforcement (95% CI 9.1–23.1%)
(I2 = 6.5). This low quality evidence suggests that the use
of mesh reinforcement during fascial closure in a BA has
a pooled proportional benefit in terms of a reduction in the
rate of incisional hernia development. However, the pooled
proportion of SSO increased when a mesh was included in
the repair. The GDG carefully considered both the low level
of evidence related to the analysis of observational studies,
as well as taking into account the high numbers of incisional
hernias (40–60%) [122, 133] and mortality (34–44%) [134]
described in the literature in association with a BA. Conse-
quently, the GDG agreed to suggest as a good practice state-
ment that mesh reinforcement should be done during fascial
closure in a BA. However, it was also noted that there was
a large degree of heterogeneity of patients included in the
studies analyzed and the GDG agreed that this suggestion for
such an intervention with the same strength for all surgical
patients would pose cost and feasibility constraints, includ-
ing diagnostic implications to identify the most appropriate
candidates. In addition, the GDG took into account the fact
that the pooled proportion of SSO was higher in the group
of patients in whom a mesh was used. As a result, the GDG
agreed that the final decision to use a mesh should be evalu-
ated by the treating surgeon.
Remarks Analyzed studies were performed in high-
income countries. The lack of substantial evidence regarding
either type of mesh used or mesh position meant no recom-
mendation could be made for either of these parameters.
Key Question 3 Patients with non-adherent or adherent
bowel loops/abdominal wall and without intestinal fistula.
Should component separation/relaxing incisions be done to
obtain fascial closure in a BA?
Recommendations: The GDG group decided to
consider KQ 4 as an unresolved issue and
decided not to formulate a recommendation on
the use of temporary static closure techniques in
a BA. As a clinical expertise guidance, NPWT
should probably be the first option if static
closure techniques are chosen to treat a BA.
Comments One observational study, a small case series,
fulfilled the criteria and was included in the evaluation
[135]. This limited and very low quality evidence was con-
sidered as insufficient to make any recommendation regard-
ing the use of component separation/relaxing incisions for
the purpose of fascial closure in a BA. As clinical expertise
guidance, the GDG agreed that the use of techniques that
separate the components of the abdominal wall in any way
must be carefully and judiciously balanced for each indi-
vidual patient, considering possible future abdominal wall
repair.
Remarks The GDG identified possible harm associated
with the use of relaxing incisions described in the obser-
vational study found. The GDG agreed therefore that more
data are needed regarding the use of this type of surgical
technique.
Key Question 4 Patients with adherent bowel loops/
abdominal wall and without intestinal fistula and when
definitive (primary) fascial closure is likely impossible
within the initial hospitalization period. Should temporary
static closure techniques* be used in a BA?
*Bogota bag (plastic silo), Negative Pressure Wound
Therapy (NPWT) (commercial and non-commercial), Mesh
bridging (inlay).
Recommendations: The GDG group decided to
consider KQ 4 as an unresolved issue and
decided not to formulate a recommendation on
the use of temporary static closure techniques in
a BA. As a clinical expertise guidance, NPWT
should probably be the first option if static
closure techniques are chosen to treat a BA.
13
 Hernia
Comments One observational study using Negative Pres-
sure Wound Therapy (NPWT) as a static closure technique
[136] fulfilled the criteria to be included, four studies ful-
filled the criteria regarding the use of mesh bridging (inlay)
[123, 124, 129, 137] while no information was found related
to any other type of temporary static closure technique in
the context of a BA. When considering the evidence relat-
ing to the use of mesh bridging, the type of patients were
heterogeneous and the mean age was 53.3  years (95%
CI 49.2–57.3 years). There were no outcome data avail-
able on SSO or rate of fistula formation. It was possible
to retrieve outcome data on the rate of development of
incisional hernias, re-BA and mortality and utilizing these
data, a proportional meta-analysis was done for each of
the above outcomes. The data from the NPWT study were
purely descriptive. For the rate of incisional hernia develop-
ment, data were included from four observational studies (49
patients) [123, 124, 129, 137]. The pooled proportion for the
rate of incisional hernia development related to the use of
mesh bridging was 68.9% (95% CI 18.9–99.6%) (I2 = 93.0).
The heterogeneity was high, which was anticipated as only
data from case series were available. For re-BA, data were
included from two observational studies (36patients) [129,
137]; the pooled proportion was 12.5% (95% CI 4.05–24.7%)
(I2 = 0). For mortality, data were included from three obser-
vational studies (40 patients) [124, 129, 137]; the pooled
proportion was 19.1% (95% CI 0.49–54.7%) (I2 = 82). The
literature search did not identify any relevant studies com-
paring the different static closure techniques in the context
of a BA. The GDG agreed that routine use of a specific static
closure technique cannot be recommended in patients with a
BA with adherent bowel loops/abdominal wall and without
intestinal fistula when definitive (primary) fascial closure is
likely within the initial hospitalization period.
Remarks Analyzed studies were performed in high-
income countries. Due to the lack of substantial evidence
relating to the use of mesh bridging no recommendation
can be made regarding this technique. Similarly, also due to
a lack of evidence, no recommendation can be made with
respect to NPWT in this setting. The GDG identified dam-
age to the fascial edges as an important cause of possible
harm associated with the use of mesh bridging which may
compromise future repairs. It was emphasized that a tech-
nique utilizing inlay mesh bridging might be related to an
increased incidence of re-BA and incisional hernia devel-
opment. Taking into account the results described in the
literature regarding static measures in the context of an OA
[7], the GDG concluded that NPWT should probably be the
first option if static closure techniques are chosen to treat a
BA. However, as in the context of an OA, the GDG strongly
agreed that the NPWT sponges should not be in direct con-
tact with exposed bowel.
13
Key Question 5 Patients with adherent bowel loops/
abdominal wall and without intestinal fistula and when
definitive (primary) fascial closure is likely within the initial
hospitalization period. Should temporary dynamic closure
techniques* be used in a BA?
* ABRA system, Wittmann Patch, ABRA system + Nega-
tive Pressure Wound Therapy (NPWT) or fascial traction
(mesh or other) + NPWT.
Recommendations: The GDG group decided to
consider KQ 5 as an unresolved issue and
therefore did not formulate a recommendation on
the use of dynamic closure techniques in a BA.
As a clinical expertise guidance MMFT+NPWT
should be used as a first option treatment
modality.
No recommendation can be made for one
dynamic closure technique over another in a BA,
due to the limited and very low quality evidence.
Comments Only three observational studies related to
mesh-mediated fascial traction + Negative Pressure Wound
Therapy (MMFT–NPWT) fulfilled the criteria and were
included in the meta-analysis [109, 111, 131]. No studies
using the Wittmann Patch or the ABRA system were found.
There were no data available on SSO, re-BA or rates of
fistula formation. The type of patients was heterogeneous,
the proportion of males was greater than 50% in all studies
and the mean age was 75.7 years (95% CI 73.8–77.6 years).
Outcome data on rates of fascial closure, incisional hernia
development and mortality were retrieved and a proportional
meta-analysis performed for these three outcomes. For fas-
cial closure, data were included from three observational
studies (28 patients) [109, 111, 131]; the pooled proportion
was 57.1% (95% CI 29.8–82.3%) (I2 = 53). The heterogeneity
was high as anticipated as only data from case series were
included. For incisional hernia, data from three observa-
tional studies (19 patients) were included [109, 111, 131]
and the pooled proportion was 36.8% (95% CI 13.3–35.5%)
(I2 = 56.7). For mortality, data were included from three
observational studies (29 patients) [109, 111, 131] and the
pooled proportion was 20% (95% CI 8.2–35.4%) (I2 = 0.6).
Due to the lack of any quality data, the GDG members could
not formulate a recommendation in favor of a specific type
of dynamic closure technique. However, the GDG agreed
Hernia
that while a BA and an OA are distinct clinical conditions,
there are many circumstances and clinical scenarios which
they share [6]. In the earlier context and in reference to the
OA, MMFT–NPWT has been shown to produce the best
results both in terms of fascial closure and risk of fistula for-
mation, at least in non-trauma patients [138]. Interestingly,
the majority of the patients in this analysis are non-trauma
cases and the pooled fascial closure rates in our analysis are
very similar to the pooled fascial closure figures related to
an OA in the literature [138] (57.1 and 50.2%, respectively).
The mortality rate was similar as well with figures of 30%
in the literature [138] versus 20% in our analysis. This high
mortality likely reflects the severity of the underlying con-
ditions in BA and OA patients. The GDG agreed that the
limited number of patients analyzed and the very low qual-
ity of data available precluded making any recommendation
regarding the use of MMFT–NPWT in these circumstances.
However, the GDG agreed to suggest as clinical expertise
guidance that MMFT–NPWT should be used as a first option
treatment modality in patients with adherent bowel loops/
abdominal wall and without intestinal fistula and when
definitive (primary) fascial closure was likely within the
initial hospitalization.
Remarks Analyzed studies were performed in high-
income countries. The GDG believes that the use of
MMFT–NPWT in BA patients might improve the chance
to achieve fascial closure. The GDG agreed that part of the
morbidity may not be related to the therapy itself.
Key Question 6 Patients with non-adherent or adherent
bowel loops/abdominal wall and without intestinal fistula
and when definitive (primary fascial) closure is possible
within the initial hospitalization period. Should abdominal
girdle (indications not to primarily close, “conservative”
management) be used in a BA?
Recommendation: The GDG decided to consider
KQ 6 as an unresolved issue and not to formulate
a recommendation on the use of an abdominal
girdle in a BA. As a clinical expertise guidance,
an abdominal girdle should only be the
therapeutic approach in a very limited number of
patients.
The literature search did not identify any relevant stud-
ies comparing abdominal girdle with any other technique or
management used in patients with a BA.
General comments
When considering the OA and guideline implementation, a
strong recommendation has been made to prioritize the use
of dynamic closure techniques over the use of static closure
techniques. It is acknowledged that the level of evidence sup-
porting this is low, as the overwhelming majority of data was
extracted from observational studies only with an anecdotal
number of RCTs. However, results from observational stud-
ies match the data from recently published registers [7, 8],
i.e., the results from the management of the OA in published
registers are in accordance with the results of pooled pro-
portional meta-analysis. Furthermore, the epidemiological
profile obtained from the analyzed data overlaps the epide-
miological profile recorded in these registers in terms of age,
proportion of males and indications for treatment of an OA.
Similarly, several recent systematic reviews and meta-analy-
ses concluded that dynamic techniques have the best results
in terms of fascial closure, although it is again noted that the
quality of evidence is very low [9, 138]. As comparative data
considering the different techniques of dynamic closure are
lacking, one specific technique cannot be recommended and
it is acknowledged that the implementation of these recom-
mendations is subject to resource availability. It is impracti-
cal to make recommendations to surgeons if the equipment/
meshes/techniques are unavailable to them. When consid-
ering suture closure techniques, the use of mesh reinforce-
ment, component separation techniques and skin grafting,
only clinical expertise guidance was provided because they
are outcomes for which there is either no published evidence
or insufficient evidence to justify a formal recommendation.
When considering the evidence for BA patients, the same
conclusions have been drawn. The quality and the level of
evidence are very low and rather scarce for all KQ. A clini-
cal expertise guidance statement advises the implementa-
tion of dynamic closure techniques in patients with a BA.
The fascial closure rate would be predicted to improve with
a decrease in incisional hernia development. Additionally,
a clinical expertise guidance statement advising on suture
closure techniques and a good practice statement relating
to mesh reinforcement during fascial closure in a BA are
presented in line with the OA literature and the current EHS
guidelines on closure of a midline laparotomy. The role and
use of advanced techniques such as component separation,
relaxing incisions or other forms of fascia and myoplasty
is questioned as there is no literature available and these
techniques might jeopardize future abdominal wall recon-
struction. In addition, the role of the abdominal girdle seems
limited and only advisable in very selected patients with no
opportunity for abdominal wall closure.
The level of evidence available to answer all the KQ in
these guidelines has exposed significant gaps in current
13
 Hernia
knowledge and clinical research addressing these issues
would be valuable. Together with other study designs, reg-
isters represent one of the best ways to improve the data
related to abdominal wall closure in the OA or BA context
as these conditions relate to very heterogeneous popula-
tions. To facilitate implementation of these guidelines, the
design and format was guided by the GRADE methodol-
ogy. As previously noted, the most important limitation of
these guidelines is the low quality of evidence (i.e., obser-
vational studies) or, for some KQ, the absence of evidence.
One shortcoming relates to the type of patient with an OA
or BA, as the majority of these patients are severely ill and
admitted to intensive care units (ICU); in this situation, the
concept of shared decision making (i.e., surgeon and patient)
disappears and the final decision on a specific therapeutic
approach has to be balanced by the surgeon and other clini-
cians in charge. Another limitation is the non-participation
of other stakeholders (nurses, policymakers and providers)
in the GDG related with this type of patient care.
According to the guidelines protocol and prior to submis-
sion of the manuscript, the guidelines were evaluated and
scored using the AGREE II instrument by three external
reviewers. The results of these assessments are presented in
Annex V. It is planned to review and update the Guidelines
in 2020.
Conclusion
These guidelines provide surgeons with a basis for decision
making when considering different therapeutic approaches
to the management of abdominal wall closure in the context
of an OA or BA. These guidelines are designed to inform
clinical decision making rather than mandate a specific
course of action, particularly as the group of patients are so
heterogenous. Patients and other stakeholders—particularly
regulatory agencies or the courts—should not view the rec-
ommendations in these guidelines as unconditional because
no guideline can account for the unique features of indi-
vidual patients and their clinical circumstances; these guide-
lines are designed to aid not replace good clinical judgment.
Acknowledgements  We acknowledge the external experts for their
review and evaluation using the AGREE II instrument of these guide-
lines prior to submission of the manuscript: Prof Manuel Armengol
Carrasco (Department of General Surgery, Hospital Universitario Vall
d’Hebrón, Universidad Autónoma de Barcelona, Barcelona, Spain),
Prof Lars Nannestad Jørgensen (Department of Surgery, Bispebjerg
University Hospital, Copenhagen, Denmark), Maarten P. Simons, MD,
PhD (Department of Surgery, Onze Lieve Vrouw Gasthuis, Amsterdam,
The Netherlands). We acknowledge the help, comments and advices of
Pablo Alonso-Coello MD, PhD (Centro Cochrane Iberoamericano-Epi-
demiología Clínica y Salud Pública, IIB Sant Pau, Barcelona, Spain)
and Prof Luis Grande Posa (Department of General Surgery, Parc de
Salut Mar, Universidad Autónoma de Barcelona, Barcelona, Spain).
13
We acknowledge the help with the online generated database to Felix
Herrmann (Institute for Artificial Intelligence and Applied Informatics
(VI), University of Wuerzburg, Germany).
Funding  These guidelines were investigator-initiated collaboration,
supported by the European Hernia Society and an educational grant
from ACELITY®. The funders had no role in the design or conduct of
the study, collection, analysis and interpretation of the data, or prepa-
ration, review or approval of the guidelines. Final decisions regard-
ing the key questions or other issues that arose during the guidelines
development process were solely the responsibility of the guidelines
development group.
Compliance with ethical standards 
Conflict of interest  The authors declare no competing interests related
with these guidelines.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Human and animal rights  This article does not contain any studies with
animals performed by any of the authors.
Informed consent  For this type of study formal consent is not required.
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Affiliations
M. López‑Cano1 · J. M. García‑Alamino2 · S. A. Antoniou3 · D. Bennet4 · U. A. Dietz5 · F. Ferreira6,7 · R. H. Fortelny8,9 ·
P. Hernandez‑Granados10 · M. Miserez11 · A. Montgomery12 · S. Morales‑Conde13 · F. Muysoms14 · J. A. Pereira15 ·
R. Schwab16 · N. Slater17 · A. Vanlander18 · G. H. Van Ramshorst19 · F. Berrevoet18
1 3
Abdominal Wall Surgery Unit, Department of General
Surgery, Hospital Universitari Vall d’Hebron, Universitat
Autònoma de Barcelona, Passeig Vall d’Hebron 119‑129,
08035 Barcelona, Spain
2
DPhil Programme in Evidence‑Based Healthcare, University
of Oxford, Oxford, UK
13
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Am Surg 64:660–665
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Department of Colorectal Surgery, Royal Devon and Exeter
NHS Foundation Trust, Exeter, UK
4
Royal Bournemouth and Christchurch Hospital, Castle Lane
East, Bournemouth BH7 7DW, UK
5
Department of General and Visceral Surgery, Cantonal
Hospital of Olten,, Olten, Switzerland
Hernia

6 13
Department of Surgery: Upper Gastrointestinal Unit of Innovation in Minimally Invasive Surgery, General
and Abdominal Wall Surgery, Pedro Hispano Hospital, and Digestive Surgery Unit, University Hospital Virgen del
Matosinhos, Porto, Portugal Rocío, Seville, Spain
7 14
Department of General Surgery, CUF, Porto Hospital, Porto, Department of Surgery, Maria Middelares Hospital, Ghent,
Portugal Belgium
8 15
Department of General, Visceral and Oncological Surgery, Servei de Cirurgia General, Hospital del Mar, Parc de Salut
Wilhelminenspital, Vienna, Austria Mar, Departament de Ciències Experimentals i de la Salut,
9 Universitat Pompeu Fabra, Barcelona, Spain
Medical Faculty of Sigmund Freud University Vienna,
16
Vienna, Austria General and Thoracic Surgery, Federal Armed Forces Central
10 Hospital, Koblenz, Germany
Unidad de Cirugía General, Hospital Universitario Fundación
17
Alcorcón, Alcorcón, Madrid, Spain Department of Plastic and Reconstructive Surgery, Radboud
11 University Medical Center, Nijmegen, The Netherlands
Department of Abdominal Surgery, University Hospitals
18
Leuven, Leuven, Belgium Department of General and HPB Surgery and Liver
12 Transplantation, Ghent University Hospita, Ghent, Belgium
Department of Surgery, Malmö University Hospital, Lund
19
University, Malmö, Sweden The Netherlands Cancer Institute, Amsterdam,
The Netherlands

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