Temporary Abdominal Closure 
Richard Davis, Sharmila Dissanaike 
 
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  
 
Introduction:  
There are several reasons why a surgeon 
would want to close the abdomen temporarily. 
Broadly, these fall under two categories: overall 
patient condition, and intra-abdominal condition. 
There is usually overlap among these two; patients 
with severe intra-abdominal conditions often have a 
severe illness and poor condition overall.  
 
Patients with poor overall condition are those 
who are too sick for an extended operation: the 
appropriate treatment is “damage control.” When 
patients are in severe hemorrhagic or septic shock, an 
experienced surgeon will often decide in advance 
that the patient is in “damage control” mode. The 
focus becomes on controlling the bleeding or 
eliminating the source of sepsis and getting the 
patient to the ICU for further resuscitation and 
rewarming. Especially with hemorrhagic shock, you 
must get out of the operating room before the “lethal 
triad” 
sets 
in: 
hypothermia, 
acidosis, 
and 
coagulopathy.   
In other situations, the patient’s condition 
deteriorates unexpectedly in the middle of a 
laparotomy, due to acute myocardial infarction, 
pulmonary 
embolism, 
or 
rarely, 
malignant 
hyperthermia. 
When 
the 
patient’s 
condition 
deteriorates, this type of closure helps you get the 
patient out of the operating room much faster.  
 
Alternatively, sometimes it is an intra-
abdominal condition that prevents you from closing 
the 
abdomen. 
One 
example 
is 
abdominal 
compartment 
syndrome. 
The 
intra-abdominal 
contents will not fit into the space that would remain 
after closure, due to edema. If you were to “force” 
this closure, the result would be the triad of 
abdominal compartment syndrome:  
● Decreased ventilation due to pressure on the 
diaphragm,  
● Low blood pressure due to decreased preload 
(pressure on the vena cava) and direct pressure 
on the heart itself, 
● Low urine output due to decreased perfusion of 
the kidneys and direct pressure on them.  
 
The surgeon will frequently be faced with 
bowels that are difficult to return to the abdominal 
cavity, but it is rare for true abdominal compartment 
syndrome to become apparent during abdominal 
closure. If abdominal compartment syndrome seems 
likely, ask the anesthetist what is the peak airway 
pressure (at the end of inspiration) at the beginning 
of closure and then check it again at the end. If the 
pressure rises by more than 15cm H20 after 
abdominal closure, consider reopening and applying 
a temporary closure device, especially if the blood 
pressure has dropped during closure as well.  
Regardless of the technique used for 
temporary closure, the sooner the patient returns to 
the operating room for definitive closure, the better. 
The surgeon should aim for return to OR within 24-
48hours. Delays longer than 72hours, and certainly 
longer than a week, greatly increase the risk of failure 
to achieve primary fascial closure during the index 
admission. When an abdomen is left open, the 
abdominal wall muscles, without their insertion at 
the lateral edge of the rectus sheath, begin to retract 
laterally. This makes closure progressively more 
difficult. The longer the abdomen is left open, the 
greater the eventual difficulty. After 7-10 days, it 
may become impossible to achieve primary fascial 
closure, which greatly complicates the patient’s 
hospital stay and ultimate recovery. In addition, the 
longer the abdomen is left open, the greater the risk 
the bowel will become desiccated, or injured, and 
start to leak enteric contents. If this occurs, an 
“entero-atmospheric fistula” may occur; this is a 
catastrophic complication that can be more difficult 
to manage than the patient’s original diagnosis! 
 
Choice of closure technique 
The goal of any temporary abdominal closure 
technique is to cover the intestines temporarily and 
to prevent excessive fluid and thermal losses from 
the open abdomen. In all cases these closures are to 
be considered temporary: the fascia should be 
reapproximated as soon as possible. In cases where 
the fascia is damaged, or fascial dehiscence has 
already occurred once or more, use the closure 
technique described in Closure of Laparotomy 
Wound Dehiscence. 
Whenever 
possible 
we 
favor 
the 
“Whipstitch” 
technique 
as 
described 
below. 
Temporary Abdominal Closure 
Richard Davis, Sharmila Dissanaike 
 
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  
 
Whipstitch is quick and easy to perform and requires 
no special supplies or training. It has the added 
benefit of covering intestine with the patient’s own 
biologic tissue, rather than plastic or other synthetic 
substances that tend to cause more irritation. This 
technique is not suitable for use in compartment 
syndrome, although it works well for other 
indications for open abdomen. 
 
In cases where the skin edges cannot be 
brought together, such as abdominal compartment 
syndrome, we recommend temporary vacuum 
closure as described in this article. This controls fluid 
drainage better, and causes less damage to the fascia, 
than the “Bogota bag.”  
The “Bogota bag” closure is a well known 
method. It consists of cutting a sterile IV fluid bag to 
the shape of the fascial incision and suturing it to the 
fascial edges. We usually do not use this technique 
because it takes more time to deploy than either of 
the two simple closure techniques described here. 
Another disadvantage is that the bag is sewn to the 
fascial edges, which damages them and makes 
definitive closure more difficult later.  
However, if you do not have a large sheet of 
adhesive plastic or reliable continuous suction, and 
you cannot bring the skin edges together, this 
technique may be useful for temporary closure. 
Expect the abdominal incision to leak continuously, 
and plan to close the fascia as soon as you can.  
 
The Bogota bag is an opened IV fluid bag sutured to the edges 
of the fascia. Suarez-Grau JM, Guadalajara Jurado JF, Gómez 
Menchero J, Bellido Luque JA, CC BY 4.0 
https://creativecommons.org/licenses/by/4.0  via Wikimedia 
Commons 
 
Temporary abdominal closure generally 
occurs in the following steps:  
● Decision: as described above, the patient’s 
condition warrants temporary closure. 
● Attempt to “Whipstitch” the skin together as 
described further below. Usually this technique 
is sufficient.  
● If “Whipstitch” fails, placement of a sterile 
plastic barrier over the intestines 
● Placement of two unfolded laparotomy sponges 
and a nasogastric tube within the skin incision 
● Cleaning of the skin and placement of an 
adhesive sheet of plastic 
● Applying suction to the nasogastric tube.  
 
Technique: “Whipstitch” 
1. If it is possible to approximate the skin edges, 
bring them together in the midline with a large 
suture, such as 0 Nylon, in continuous running 
fashion. 
2.  The sutures should be placed approximately 1cm 
back from the skin edge, and spaced 1cm apart. 
 
Using 0 Nylon or other monofilament on a cutting needle, 
suture only the skin together. The surgeon on each side of the 
patient begins at one end of the wound and the sutures meet in 
the middle. Tie the sutures together to complete the closure.  
 
3.  It is important to only suture skin and 
subcutaneous fat and leave the fascia untouched. 
This allows for a healthy fascial edge to be 
Temporary Abdominal Closure 
Richard Davis, Sharmila Dissanaike 
 
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  
 
preserved for definitive closure, to reduce the risk 
of subsequent hernia that is significant risk in 
these cases. 
4. Since the whipstitch technique is more easily 
mistaken for definitive closure than other forms 
of temporary closure, it is recommended the 
surgeon label the patient’s abdomen as open, 
either directly on skin or on the dressing, or both.  
 
Writing on the dressing alerts the team that this is not an 
ordinary abdominal closure, despite its appearance.  
 
Technique: Temporary Vacuum Closure 
1. Obtain a piece of plastic that is sterile: a sterile x-
ray plate cover, some sterile inner packaging, or 
a urine bag that has been cut open. Also obtain a 
sheet of adhesive plastic; this does not need to be 
sterile though ideally it should be.  
2. Pull the drapes back and thoroughly clean and 
dry the skin around the incision circumferentially 
for 15-20cm, including the inguinal folds. First 
clean with saline and dry the skin, then clean with 
alcohol and allow it to air dry.  
3. The plastic sheet acts as a barrier to prevent the 
laparotomy sponge from coming in contact with 
the bowel. Lay it over the bowel, inside the 
peritoneal cavity, to overlap the edges of the 
incision.  
 
A piece of sterile plastic is placed inside the abdominal cavity, 
between the bowel and the anterior peritoneum, overlapping 
the incision by at least 10cm. In this case, a sterile urine bag 
was cut on 3 sides and then unfolded.  
 
4. Lay two laparotomy sponges in the wound. Do 
not place any part of them inside the abdominal 
cavity, they should be flush with the fascial edges 
only.  
 
Temporary Abdominal Closure 
Richard Davis, Sharmila Dissanaike 
 
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  
 
Laparotomy sponges are placed in the wound to cover the 
plastic. These lie in the wound but not inside the 
abdominal cavity, to decrease the chance that bowel will 
come in contact with the sponge material. It is not 
necessary to wet the sponges.  
 
5. Lay an NG tube so that the holes on the end are 
within the folds of one of the lap sponges.  
 
A NG tube is laid within the folds of the laparotomy sponge so 
that its holes are not in direct contact with either piece of 
plastic, to make it less likely that the tube’s holes would become 
blocked.  
 
6. Immediately before applying the adhesive sheet, 
check again that the skin is dry and that no further 
fluid has leaked out from the incision, or out of 
the ostomy if present. The skin should be clean 
and dry. 
7. Lay a large adhesive sheet over the wound, 
overlapping the edges by more than 15cm if 
possible. Raise the NG tube off the skin a little so 
that it is completely encircled by the adhesive 
sheet to assure a good seal.  
8. Connect the NG tube to suction. The lap sponges 
should collapse.  
 
Adhesive plastic is applied over the whole abdomen. In this 
case, the plastic was applied directly over a colostomy, making 
sure the surrounding area was dry. The plastic over the 
colostomy was then trimmed and an ostomy appliance was 
applied directly to the plastic.  
 
Pitfalls 
● Patients with temporary abdominal closure in 
place should ideally be kept intubated and 
sedated: a cough or strong Valsalva could disrupt 
the whole closure and result in evisceration. If 
you do not have an Intensive Care Unit, and you 
cannot transfer the patient to one while still 
intubated, your options are limited to heroic 
measures. In some settings the patient can be 
“bagged” by hand, but this must be sustainable 
for several days. Otherwise you may choose to 
take your chances and close the patient. In either 
case, they are unlikely to survive. Damage 
control laparotomy and temporary closure are 
essentially useless without ICU care.  
● Temporary abdominal closure takes much less 
time than standard closure. If you do not 
Temporary Abdominal Closure 
Richard Davis, Sharmila Dissanaike 
 
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  
 
communicate well with the team, you may finish 
quickly, only to find that the ICU bed or transport 
equipment is not ready. Communicate early that 
you are in damage control mode so the team can 
plan the next steps accordingly.  
● Over time, the lateral abdominal wall muscles 
retract 
and 
midline 
closure 
becomes 
progressively more difficult. Generally closure 
becomes impossible after 7 days. If the patient’s 
condition has not improved enough to close the 
abdomen by then, you have no choice but to treat 
this as an open abdomen. Protecting the exposed 
small bowel is very difficult and requires very 
diligent nursing care.  
● If a sheet of adhesive plastic is not available, this 
solution may be impossible. This closure 
depends on maintaining suction in the abdominal 
wound and removing fluids as they accumulate. 
We use kitchen plastic wrap (taped to the skin 
around the edges) for vacuum- assisted wound 
closure elsewhere in the body, but we have never 
used it in the abdomen. The Bogota bag, 
described briefly above, may also be used in this 
situation.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Sharmila Dissanaike MD FACS FCCM 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA 
 
October 2022 
