Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
An enterocutaneous fistula is one of the most 
feared complications for the abdominal surgeon. It 
can be the devastating consequence of a single lapse 
in judgment during a long, tedious operation, either 
by yourself or another surgeon.  
The three stages of fistula management are 
classically described as resuscitation and infection 
control, investigation, and intervention. In this 
chapter, we will focus on the latter two stages, and 
the difficult management decisions and strategies to 
get you to a successful result. Regarding the first 
stage, remember that a leaking intestine inside the 
abdomen will leak into the peritoneum before finding 
its way to the skin. Sepsis control consists of draining 
the peritoneum and assuring a consistent exit of the 
leakage. Usually this will involve re-opening the 
abdominal incision, or making a new opening over 
the leaking site, and not closing it. This results in the 
dreaded “open abdomen.” We discuss this entity here 
as well.  
 
The best possible outcome for a fistula is for 
it to close on its own. In deciding whether this 
outcome is likely, remember the FRIENDS of a 
fistula. These are conditions that make a fistula less 
likely to close spontaneously:  
● Foreign body (including mesh) 
● Radiation history 
● Infection 
● Epithelization of the tract (this is especially 
important in anal fistulas, a different subject.)  
● Neoplasia 
● Distal obstruction: this one is especially 
important in the open abdomen, and is also 
responsible for many anastomotic leaks!  
● Steroid use 
 
In our opinion, it is a failure of understanding 
to try to treat a fistula by only making a patient 
“NPO,” placing them on parenteral nutrition, and 
waiting for the fistula to close on its own. Although 
this approach might be needed with very proximal 
fistulas, in most situations there are other options that 
cost less money and allow a patient to experience the 
joy of eating. In any event, in a resource-limited 
setting, prolonged hospitalization and parenteral 
nutrition are not realistic options.  
 
Anatomy:  
The lateral abdominal wall muscles originate 
at the posterior aspect of the abdominal cavity, along 
the lumbodorsal fascia and other midline posterior 
structures. They insert into the lateral aspect of the 
rectus sheath on each side. If the two rectus sheaths 
are separated, as in open abdomen, the lateral 
abdominal wall muscles will retract. After about 7 
days, this retraction is so extensive that the 
abdominal incision can not be closed again without 
measures such as components separation.  
 
When the linea alba, between the two rectus muscles (Straight 
dotted line) is divided, the lateral abdominal wall muscles begin 
to contract, unopposed, towards their origin (Purple arrows.) 
If this contraction is allowed to persist for more than 7 days, it 
may be impossible to reapproximate the linea alba at the 
midline. An “open abdomen” is usually the result. 
 
Within the abdominal cavity, any sort of 
intervention leads to severe inflammation. Especially 
if there is spillage of enteric contents or of purulent 
material, this inflammation can be significant. As a 
general rule of thumb, if the patient had an 
uncomplicated laparotomy, you should not attempt 
to operate in their abdomen during the time period of 
2-6 weeks after surgery. If there was spillage of 
succus or infection, do not operate for at least 3 
months: 6 months would be preferable. Failure to 
heed these timelines leads to a difficult and bloody 
operation that has a very high chance of causing an 
inadvertent enterotomy.  
If you are operating on a patient with 
malnutrition 
or 
severe 
intra-abdominal 
contamination, it is best to avoid any bowel 
anastomosis or suture if possible. If you must suture 
bowel, there are several options for reinforcing the 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
suture line, including omentum, the gastroepiploic 
arcade, and the round and falciform ligaments. The 
classic example of such reinforcement is the Graham 
patch for closure of a duodenal perforation. Some of 
these options are described further below in 
“Prevention.”  
 
Succus entericus, the content of the small 
intestine, is very caustic and damaging to both 
peritoneum and skin. This is why most surgeons 
recommend avoiding operation for 3-6 months after 
intraperitoneal spillage. But the surgeon should also 
do their best to prevent this fluid from coming in 
contact with the skin. Once the skin is irritated, it will 
be painful to the patient and much more difficult to 
apply dressings or ostomy appliances to. One 
common mistake is cutting the hole in the ostomy 
appliance too big: it must be trimmed to almost 
exactly the size of the exposed mucosa or wound. 
Peri-wound or peristomal skin excoriation is much 
better avoided than treated, as we describe further 
below.  
 
An ostomy appliance that has been cut too large exposes the 
skin to enteric contents (within solid Red circle) which can 
cause irritation over time. It would be better to cut the 
appliance to just a little smaller than the ostomy (dashed Red 
circle.) 
 
 
Small bowel is very adaptable. Over time, it 
can make itself more able to absorb nutrients and 
water according to the needs of the patient. Surgeons 
caring for patients with “short gut syndrome” have 
found that the intestine can adapt so much that an 
adult can survive with only 75 cm of small intestine. 
However this transition takes several months; in 
high-resource settings, patients are helped through 
this time with total parenteral nutrition. In our 
settings, patients may survive with as little as 100 cm 
of small intestine, but this process is very difficult for 
both the patient and the surgeon. We offer some tips 
for slowing bowel transit, increasing absorption, and 
avoiding dehydration below.  
 
Principles:  
 
We divide this section into three parts:  
● Prevention, 
including 
dealing 
with 
an 
intraoperative enterotomy that is at risk for 
becoming a fistula 
● Wound care, including prevention of further 
injury to exposed bowel and isolating fistula 
output. 
● Output management, including thickening the 
succus, slowing transit time, and maximizing 
enteral nutrition.  
 
Prevention: 
Preventing an enterotomy is much better than 
treatment. Recognize situations where you are at risk 
for developing an enterocutaneous fistula. Try as best 
you can to avoid operating in the abdomen between 
2 and 6 weeks after the most recent laparotomy. If 
there was infection or excessive contamination, wait 
3 months at a minimum.  
When 
performing 
adhesiolysis, 
use 
meticulous surgical technique including sharp 
dissection. For especially tightly scarred adhesions, 
we sometimes use a scalpel to carefully open up the 
plane between two serosal surfaces. Use diathermy 
only if there is an easily seen plane of tissue between 
the objects you are trying to separate. Avoid blunt 
dissection with a fingertip, tearing adhesions. The 
fingertip will enter much more readily into the lumen 
of the bowel rather than the adhesed space between 
loops of bowel.  If you expect difficult adhesions and 
a “hostile” abdomen, be sure to give yourself enough 
time for these operations; consider allotting the 
whole day for such patients.  
If you are operating on a patient who is 
malnourished, if the bowel cannot be mobilized, or if 
there are extensive dense adhesions, you may get an 
inadvertent enterotomy. This is very difficult 
situation to manage. It is tempting to put a few 
stitches and close the bowel in this situation. This 
approach will inevitably fail. Do your best to 
mobilize the enterotomy enough to create an ostomy, 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
separate from the abdominal incision or, in last 
resort, through it.  
If your inadvertent enterotomy is in the 
duodenum or proximal jejunum, you must repair it 
because an ostomy here would be incompatible with 
life. Reinforce your repair with omentum, as you 
would with a perforated duodenal ulcer. If the 
omentum is not available, other options include the 
round ligament of the liver or the gastroepiploic 
arcade dissected off the greater curvature of stomach.  
 
This patient had late presentation of an intraoperative injury to 
a proximal loop of jejunum. The omentum was contracted and 
could not be mobilized to the site of injury. We divided the 
gastroepiploic vessels on the left side of the stomach (Black 
arrow) and dissected these vessels to the stomach until we had 
a length of well-vascularized, fatty tissue (Blue arrow) that 
could reach the repaired jejunum. We then used this tissue to 
reinforce the repair.  
 
 
A round ligament (Ligamentum Teres) flap can be harvested 
during laparotomy by ligating the round ligament at its 
connection to the umbilicus (Black circle) and then 
disconnecting the fatty tissue within the falciform ligament from 
the abdominal wall at the midline (White circle.) This flap will 
usually reach the intra-abdominal esophagus, stomach, 
duodenum, and central parts of the liver.  
 
Wound Care 
In all cases, the best coverage of exposed 
bowel is the patient’s own tissue if possible. 
Reapproximate fascia if you can do so, especially if 
the laparotomy was within the last 7 days. This is 
especially 
important 
when 
re-operating 
for 
laparotomy dehiscence. Often if the fascia alone 
cannot be closed (if >1 week since opened,) the skin 
will still come together at the midline and cover the 
intestines. See Temporary Abdominal Closure and 
Closure of Laparotomy Dehiscence. Remember, the 
longer the intestines are exposed to the air, the more 
likely that an entero-atmospheric fistula will 
develop.  
 
For an open abdominal wound such as this one, immediate 
closure will be impossible. The exposed bowel must be 
protected and covered as soon as possible. One way to 
accomplish this is to use a device that exerts continuous 
traction on the skin and pulls it together in the midline, as 
shown. We explain this concept further in the Guide below.  
 
If you are faced with exposed bowel that can 
not be covered with skin or fascia, you must protect 
it relentlessly. Do not allow it to become dehydrated. 
If the serosa has some adherent necrotic tissue, do not 
attempt to directly debride it, no matter how 
contaminated it might appear. You may sharply 
debride fascia, muscle, or subcutaneous tissue if you 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
are sure the necrosis is involving these tissues only, 
but avoid debriding bowel directly.  
Avoid repeated dressing changes with gauze 
or sponge directly on bowel: this “wet to dry” wound 
care strategy may work well in other parts of the 
body. But it makes the wound clean by removing a 
bit of tissue every time the gauze is removed. On the 
bowel, this will inevitably lead to a fistula. Instead, 
use petroleum jelly (Vaseline®) gauze. In resource-
rich countries, the KCI Wound-Vac system has a 
proprietary “white” sponge that can be safely applied 
directly to the serosa of the bowel.  
 
 
Initial appearance of a wound after dehiscence and 
development of a fistula (Black arrow.) Sharp debridement the 
eschar should be done where possible, but avoid it on the 
surface of the exposed bowel. Source: Desvigne MN et al,  
doi:10.7759/cureus.36 
 
 
Appearance of the same wound after application of the 
principles in this chapter. The eschar on the bowel has 
decreased and granulation tissue is beginning to appear. When 
all of the eschar has disappeared and the wound is relatively 
flat, it can be allowed to close more by wound contraction, or 
the exposed bowel can be covered with a split-thickness skin 
graft and the fistula closed later. Source: Desvigne MN et al,  
doi:10.7759/cureus.36 
 
 
When caring for wounds such as these, exposed bowel must be 
covered with petroleum jelly (Vaseline®)- soaked gauze or 
other non-adhesive material. It must not be treated with serial 
“wet to dry” dressing changes or more fistulae will result. 
Here, all exposed tissue except the fistula will be covered with 
a 
vacuum 
dressing. 
Source: 
Desvigne 
MN 
et 
al,  
doi:10.7759/cureus.36  
 
 
We make our own petroleum jelly gauze by impregnating plain 
gauze with jelly in a reusable sterilizable container.  
 
If you have a combination of exposed serosa 
and a fistula opening, the best strategy for wound 
care is to keep the enteric contents and the rest of the 
wound separate. You may choose to intubate the 
fistula with a tube that will stay in place on its own, 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
such as a Malecot or T-tube, especially if the fistula 
opening is small. Some authors recommend this 
practice and others do not. If a tube will make 
management easier for you, do not hesitate to do so 
(it may help align a wound protection device or a 
vacuum device.) But do not imagine that the tube will 
drain all of the effluent. As you use the strategies 
described here to make the effluent thicker, it will 
block the tube and management will be easier 
without it.  
Attempt to isolate the fistula from the rest of 
the wound and collect its effluent separately. Use 
barrier devices to divert and collect enteric contents 
and protect the wound. Resource-rich countries have 
dedicated silicone devices that create a barrier 
around the fistula site.  
 
Commercially available silicone fistula management devices, 
such as these from KCI™ can be trimmed as needed and used 
with commercial negative pressure wound therapy devices. 
Source: 
https://www.acelity.com/healthcare-
professionals/global-product-catalog/catalog/fistula-solution-
devices  
 
 
In our setting, such devices are usually not 
available and we must be creative. Baby bottle 
nipples, especially those intended for babies with 
cleft palate, can be useful. We have also used the 
silicone from an ambu-bag, cut into the shape of 
a “fence” to isolate the stoma from the rest of the 
wound. A silicone cupcake mold with a hole cut 
in the base, or other modified silicone items, 
would probably work well for this purpose. We 
demonstrate this kind of wound device in the 
Guide at the end of this chapter.  
 
A vacuum-assisted closure dressing applied to an open 
abdomen, with a circular silicone appliance isolating the fistula 
from the rest of the wound. We explain how to set up this 
dressing below.   
 
 
Another technique that has been described for separating stoma 
output from the rest of the wound: the “Floating Stoma” 
technique involves suturing a piece of thick plastic to the wound 
edges, making a hole over the stoma, and then suturing the 
mucosa to the hole. The bowel below the plastic can then be 
treated with serial dressing changes with petroleum jelly gauze, 
while an ostomy appliance sticks to the plastic and collects the 
effluent. You will need to frequently re-suture the mucosa to the 
plastic to maintain a seal here. Source: Gross DJ et al 
doi: 10.1136/tsaco-2019-000381 
 
 
Remember 
that 
improvised 
vacuum 
dressings and barrier devices, such as those described 
in the next section, are extremely labor-intensive and 
prone to failure. In resource-rich settings, where 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
dedicated equipment and nursing are available, they 
are usually changed every 3-5 days. In our settings, 
they will fill with succus and overflow onto the skin 
much more quickly. Do not be discouraged when this 
happens, and be prepared for a long road.  
 
Output Management 
 
In our setting, simply withholding all oral 
intake and giving long term parenteral nutrition are 
not realistic options. As much as you can, you must 
use the patient’s intestine to maintain their nutrition.  
 
Patients with “short gut syndrome” and 75 
cm of jejunum can survive if parenteral nutrition is 
used as a “bridge” for a few months while the small 
bowel mucosa adapts. In our setting, 100 cm of 
jejunum is probably enough. Decide whether this is 
the case with your patient: if the small intestinal 
fistula is at least 100 cm downstream from the 
ligament of Treitz, they will survive with the 
methods described below.  
Medications and dietary measures can be 
used to thicken the secretions. The goal is for the 
small bowel succus to be about the thickness of 
toothpaste, and for colonic fistula output to be 
formed stool. The following medications can be 
used, most effectively in combination. All patients 
with enterocutaneous fistula are on the first two 
medicines, with the final three added as needed.  
● Omeprazole and other proton pump inhibitors are 
given orally to decrease gastric secretions 
● Oral rehydration solutions: these will both 
thicken the effluent and replace lost electrolytes. 
In patients with an enteric fistula, we use double-
strength oral rehydration solution at a target dose 
of 3L per day, which the patient drinks slowly all 
day long.  
● Loperamide, an antidiarrheal. We use up to 24mg 
per day divided into three or four daily doses. At 
high doses, there is an increased risk of torsades 
de pointes and other lethal arrhythmias.  
● Codeine 
is 
very 
effective 
especially 
in 
combination with loperamide. Like all narcotics, 
this medicine has a potential for addiction if used 
for a prolonged time.  
● Diphenoxylate / atropine is very effective at 
thickening succus. It has a side effect of dry 
mouth and tachycardia. This medication may not 
be available in some countries. It may be too 
effective, especially when used in combination 
with other antimotility agents. 
 
The patient’s diet can make a large difference 
on the quality and quantity of output from the fistula. 
Feed them a diet   rich  in complex carbohydrates and 
low in fat.   Hypertonic fluids, such as  soda and fruit 
juices, should be avoided, because  they usually 
worsen  diarrhea. Remember that uncontrolled sepsis 
can cause nausea and worsen the patient’s appetite, 
so consider whether the patient has an undrained 
focus of infection.  
Using this approach along with meticulous 
wound care allows you to effectively convert the 
fistula to an “ostomy.” Then the patient can take 
nutrition orally and wait until an appropriate time for 
repair- usually 3-6 months. 
 
You will find that in some cases, as the fistula 
closes, more enteric contents will go distally past the 
fistula and come out as stool. When that happens, the 
medicines described above will cause the patient 
constipation. If the patient begins to have abdominal 
pain and constipation, taper the medicines down, 
starting with codeine because of its addictive 
potential.  
 
Decision Making: 
 
You will be faced with the following 
situations:  
 
Open Abdomen, No Fistula: Take great care of the 
exposed bowel and try to close the fascia or skin over 
it progressively! Do not debride necrotic tissue 
directly on the bowel, and do not apply anything 
except petroleum jelly-soaked gauze or other 
compatible material directly to the bowel.  
 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
This open abdomen has been cared for well: the exposed bowel 
has completely granulated. This wound could be treated with a 
split thickness skin graft (covered after placement for 5 days 
with a vacuum dressing) or with a continuous traction 
technique as described in the Guide below.  
 
Open Abdomen With Fistula: Keep the wound clean 
and try to keep enteric contents away from the skin 
using the techniques described in this article. Try to 
decide if the fistula is >100 cm from the ligament of 
Treitz. There are several ways to do this:  
● Carefully examine any films you may have, 
especially a CT scan with oral contrast.  
● Perform a Gastrografin small bowel study and 
examine the films carefully to estimate how 
much bowel is present before the fistula. The 
radiographer may need to take films earlier than 
usual for very high fistulas.  
● Attempt to use techniques described in the 
previous section to thicken the succus and slow 
transit time. If, on maximum dosages, the output 
is still >500cc per day, likely you will not 
succeed with non-operative management.  
 
If the fistula is more than 100 cm from the 
ligament of Treitz, your main problems become 
wound care, keeping the patient hydrated and free of 
infection, and psychological care of the patient. This 
last matter is not trivial, we will discuss it further 
below.  
If the fistula is less than 100 cm from the 
Ligament of Treitz, this is where prolonged TPN and 
bowel rest would be used in a resource-rich setting. 
Examples include duodenal, pancreatic, biliary or 
proximal jejunal fistulas that have already failed 
multiple attempts at operation. In our setting, the 
only option is to operate and attempt to close the 
fistula. You must use meticulous sharp dissection, 
reapproximate bowel under no tension, and reinforce 
your closure with well-vascularized tissue as 
described above. Remember that this closure will fail 
if there is distal obstruction.  
During any of these operations, if you have 
any reason to suspect distal obstruction, take no 
chances. The patient may have a colon tumor, 
stricture at a previous anastomosis or ostomy site, or 
extensive adhesions. Make an ileostomy or 
jejunostomy that leaves at least 100 cm, preferably 
much more. If you form the ostomy well, its output 
will be easier to manage. 
Patients with a colonic fistula may only need 
loperamide and oral rehydration solutions. Patients 
with more proximal fistulas may need all of the 
medications, with their risks of side effects. Keep the 
patient on IV fluids as you titrate the dosages 
upwards.  
It is tempting to try to refeed secretions to the 
distal small intestine as they come out of the fistula. 
This option is frequently discussed in textbooks. In 
practice this is very difficult to do, especially in low-
resource settings. It cannot be done by bolus feeds, 
as there is no gastric reservoir; the feeds inevitably 
reflux back into the wound if given as a bolus. 
Attempting to feed them by “dripping” them into the 
intestine will inevitably block the tubing, as you 
likely do not have a pump.  
 
Open Fistula, Now Controlled 
 
Once the wound is clean and you are able to 
successfully control the output, the next question is 
how to treat the wound. If it is getting smaller on its 
own, continue your current treatment. It may reach a 
steady state, or it may continue to shrink and close 
on its own. As it becomes smaller, decide whether a 
simple ostomy appliance can be trimmed to fit 
directly over it. In general, your goals are to make the 
appliance stick to the skin and to keep the  efflux 
from contacting the skin. It is acceptable to allow 
some of the efflux to pool in the wound, as long as it 
does not go anywhere else. You may be able to 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
discharge the patient at this time, if they are able to 
care for the wound well.  
 
This wound, which previously needed a vacuum-assisted 
dressing and fistula isolation, eventually got small enough that 
an ostomy appliance alone could be applied. In fact, the wound 
likely contracted further since the last appliance was placed. As 
this occurred, the skin came in contact with the bowel contents 
and got excoriated as shown. We would not do any further 
intervention on this wound, except possibly to decrease stool-
thickening agents as output decreases and more enteric 
contents remain within the intestines. .  
 
 
If the wound still has large amounts of 
exposed bowel, but is otherwise very clean, you may 
skin graft the serosal surface of the bowel. At this 
point your vacuum dressing should be able to stay in 
place for 4 or 5 days without being changed. Apply a 
skin graft under the vacuum dressing, along with 
your barrier device that directs the efflux into the 
ostomy bag.  
 
This patient had an injury to the ileum during attempted repair 
of an incarcerated incisional hernia. An open abdomen 
resulted, with exposed bowel and a single fistula. The wound 
was managed as described here until the exposed bowel could 
be skin grafted. The fistula now functions as an ileostomy: an 
appliance can be fitted to it and the patient can eat and maintain 
nutrition until an ideal time for definitive repair. Photo courtesy 
of Dr. Demetrios Demetriades. 
 
Previous Fistula, Now Converted To “Ostomy” 
These patients will (understandably) be eager 
to have their ostomy closed. Many will have an 
incisional hernia that must be repaired at the same 
time. It is best to wait 6 months if you can, to operate 
on this type of abdomen. If the patient is very 
disturbed by the fistula, 3 months may be acceptable 
but this is a minimum. If you have applied a skin 
graft directly to bowel, you must be able to pinch it 
and feel that it is freely mobile over the bowel.  
 
 
 
This patient had an open abdomen (without fistula) and had a 
skin graft applied directly to the bowel. Now, the skin is freely 
mobile and can easily be “pinched” away from the bowel. He 
is ready for repair of his incisional hernia.  
 
You will have the greatest chance of success 
if you wait until all the inflammation has completely 
died down. These are lengthy and difficult 
operations, with careful adhesiolysis of all of the 
small bowel, resection of the fistula and anastomosis, 
and likely component separation for closure. Some 
advocate having two teams for these operations: one 
to do the lysis of adhesions, fistula takedown, and 
anastomosis, and another to do the components 
separation and fascial closure. This is wise advice.  
 
Emotional Toll of Fistula 
 
This condition is very disturbing for both the 
patient and the physician. The patient will very 
quickly realize that when they eat and drink less, 
there is less output from the fistula. Especially if 
output causes pain, or an embarrassing smelly mess, 
they will restrict their oral intake. Nothing could be 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
worse for them- they need nutrition most of all! 
Avoid this situation, first by decreasing and 
controlling fistula output as described here, and 
second by explaining the situation to the patient and 
encouraging them. Encourage the family also, to stay 
at the bedside if your hospital allows, or to visit 
frequently.  
 
As a surgeon you will also find these cases 
exhausting, especially if you feel that the fistula was 
caused by an error on your part. Learn what lessons 
you can from the case. Do not let your discomfort 
with the patient’s condition cause you to avoid them. 
Ask a more senior colleague for help if you need it. 
See Managing Complications Part 1- Yourself.  
 
Guide: Closure of Skin Over Open Abdomen by 
Continuous Traction 
 
We show a proprietary system, the Top 
Closure Tension Relief system below. It may be 
possible to modify ordinary Zip-Ties (used in 
automotive and other applications) to this purpose. 
This approach has been well described for closing 
lower extremity and other wounds after fasciotomy.  
 
A system for closing wounds slowly over time using nylon 
ratcheting ties. Source: Ahmad I et al,  
https://www.doi.org/10.36106/ijsr  
 
 
Once the decision is made to treat the wound in this manner, 
the devices are sutured or stapled to the skin in multiple 
locations. Shown is the Top Closure Tension Relief system. This 
system consists of an adhesive plate which both sticks to skin 
and is sutured to it, placed 2cm from edge and skin staples. The 
provided straps go between: tightening them a few mm every 
time the dressing is changed allows the wound to be gradually 
closed. 
 
 
The bowel is protected using material that is designed to be in 
contact with it. As shown in this chapter, petroleum jelly-
impregnated gauze is also acceptable. Plain gauze is not. This 
photo shows commercially made foam that is purpose-designed 
with one side that is non-adherent. Other options include 
coating one side of the foam with Tegaderm wound dressing, or 
applying a plastic sheet such as a cut urine bag, to the bowels.  
 
 
The entire assembly can be covered with a negative pressure 
dressing to control output and keep the wound moist. This is 
changed every 3-5 days, with the system tightened at the time. 
Serial changes of the outer dressing with tape and dry gauze 
are also acceptable, but more labor-intensive.  
 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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The devices are tightened a few mm every alternating day until 
the skin meets at the midline. At this time the devices can be 
removed.  
 
 
The final result is a wound that is completely covered in the 
patient’s own abdominal skin, and an incisional hernia 
underneath.  
 
Guide: Fistula Isolation and Negative Pressure 
Dressing 
It is very important to control the output of 
the fistula. If leakage gets out of your control, the 
skin becomes excoriated and further management 
becomes very difficult: no appliance will stick to the 
skin. You will have a very painful and messy 
situation.  
Remember that at best, a setup like this will 
last 2-3 days. The more liquid the output is, the more 
difficult it is to manage. Some liquid will inevitably 
sneak around the silicone barrier into the gauze 
sponge. Once liquid fills the gauze, it will overflow 
onto the skin and begin irritating it. Change the 
dressing before this happens! 
 
 
This patient with severe malnutrition had wound dehiscence 
after laparotomy for internal hernia with bowel resection. 
Enteric contents were seen in the wound in the area inside the 
Red circle. Our strategy will be to isolate this part of the wound 
from the rest of it, and to collect the effluent in an ostomy bag. 
 
 
This patient had an operation for suspected bowel ischemia two 
weeks after laparotomy for incarcerated incisional hernia. 
During abdominal entry, an enterotomy was made and the 
abdomen was found to be “frozen.” No attempt at repair was 
made and the wound was left open. The mucosa of the bowel is 
clearly visible within the Black circle. We will attempt to isolate 
it, collect its output, and apply a vacuum dressing to the rest of 
the wound.  
 
1. Debride necrotic tissue sharply on the fascia and 
wound edges. Do not attempt to debride any 
necrotic tissue directly on bowel.  
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The necrotic edges of the abdominal wall are sharply debrided, 
but no attempt is made to debride the necrotic tissue on the 
surface of the bowel itself.  
 
2. Apply petroleum jelly-soaked gauze to the 
exposed bowel, except for the fistula site itself. 
Leave room for your appliance.  
 
Petroleum jelly-soaked gauze is applied to the exposed bowel, 
except at the fistula site itself.  
 
3. Apply the appliance directly to the bowel 
adjacent to the fistula site. Make sure no gauze is 
under your appliance: it should be applied 
directly to the bowel, completely outside the 
fistula site.  
 
For a small fistula opening, a silicone nipple from a feeding 
bottle for infants with cleft palate (inset, Red circle) is trimmed 
and used. 
 
 
For a fistula opening that is larger than the nipple of a feeding 
bottle, a piece of convex silicone from a pediatric ambu-bag can 
be cut and used as a “fence” around the fistula site.  
 
 
The “convex” portion of the ambu-bag above, cut into a strip, 
used as a “fence” around the fistula. This allows the rest of the 
wound to be within a suction dressing.  
 
4. Fill the wound with dry gauze. If the fistula is in 
the center of the wound and you need suction on 
both sides, use a “bridge” of gauze to one side of 
the appliance. Alternatively, place closed suction 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
drains through the skin into the wound. Both 
options are shown here.  
 
With the baby bottle nipple in place, the rest of the wound is 
filled with gauze, including a “bridge” around the appliance. 
The gauze can pass to both sides of the appliance as shown, or 
to only one side.  
 
 
Here, closed suction drains under the skin enter the wound on 
both sides of the silicone appliance, so it is not necessary to 
leave a “bridge” of gauze around it. 
 
5. Apply the adhesive dressing over the gauze and 
the appliance. Ideally, the appliance is a little 
taller than the gauze, so that when suction is 
applied it will be pressed downward onto the 
wound.  
 
Holding the gauze and silicone appliance in place, the adhesive 
plastic dressing is applied.  
 
6. Cut a small hole in the adhesive dressing and 
insert a trimmed nasogastric tube into the gauze. 
Cover this junction with a small piece of adhesive 
dressing.  
 
A nasogastric tube is passed through a hole in the adhesive 
plastic, and then a smaller piece of plastic is used to make this 
connection airtight. Suction applied to the NG tube will now 
exert continuous suction on all of the gauze sponge.  
 
7. Trim the part of the adhesive dressing that covers 
the appliance. 
Management of Open Abdomen and Enteric Fistula 
Richard Davis, Daniel Moenga, Elizabeth Mwachiro 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
With a scalpel or scissors, trim the part of the plastic that covers 
the silicone appliance, making sure part of it remains adherent 
to the silicone.  
 
8. Engage suction and confirm that there is minimal 
leakage around the appliance.  
9. Trim the ostomy hole to the size of your 
appliance.  
 
Measure the size of the hole in the silicone appliance and trim 
the ostomy wafer to the same size.  
 
10. Apply the ostomy directly to the dressing, over 
the appliance.  
 
Finally, the ostomy bag is positioned so that it will catch all 
output from the ostomy.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Daniel Moenga MBBS FCS(ECSA) 
Tenwek Hospital 
Kenya 
 
Elizabeth Mwachiro MBBS FCS(ECSA) 
Tenwek Hospital 
Kenya 
 
 
 Resource-Rich Settings 
Total Parenteral Nutrition 
Octreotide 
Wound Vac ® system and “White Sponge” 
Teduglutide (Gattex) to promote mucosa growth (in 
Short Bowel Syndrome) and nutrient absorption 
