Clin Colon Rectal Surg 2022; 35(03): 169-176
DOI: 10.1055/s-0041-1740043
Review Article

Management of the Hostile Abdomen

Megan Lundy
1   Division of Colorectal Surgery, Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, North Carolina
Jean H. Ashburn
1   Division of Colorectal Surgery, Department of Surgery, Wake Forest University Baptist Health, Winston-Salem, North Carolina
› Author Affiliations


Caring for a patient with a hostile abdomen is one of the most challenging clinical situations one can encounter. It requires specialized technical skill coupled with bold but thoughtful decision-making to achieve good outcomes. An approach to the patient with a complex, hostile abdomen must be individualized to account for the patient's personal details. However, implementing an experienced-based algorithm to help make the difficult decisions required in this setting can be helpful, as evidence-based studies are few. The purpose of this review is to provide a structured, evidence, and experienced-based approach to the challenges that the surgeon encounters when faced with a patient with a hostile abdomen, and to discuss perioperative and intraoperative surgical strategies that can lead to most successful outcomes.

Publication History

Article published online:
12 August 2022

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  • References

  • 1 Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg 2007; 96 (04) 263-271
  • 2 diZerega GS. Biochemical events in peritoneal tissue repair. Eur J Surg Suppl 1997; (577) 10-16
  • 3 Ahrendt GM, Tantry US, Barbul A. Intra-abdominal sepsis impairs colonic reparative collagen synthesis. Am J Surg 1996; 171 (01) 102-107 , discussion 107–108
  • 4 Salmo EN, Haboubi NY. Radiation bowel disease and its clinical implication. Acta Chir Iugosl 2010; 57 (03) 51-54
  • 5 Haboubi NY, El-Zammar O, O'Dwyer ST, James RJ. Radiation bowel disease: pathogenesis and management. Colorectal Dis 2000; 2 (06) 322-329
  • 6 Ashburn JH, Kalady MF. Radiation-induced problems in colorectal surgery. Clin Colon Rectal Surg 2016; 29 (02) 85-91
  • 7 Visschers RGJ, Olde Damink SWM, Winkens B, Soeters PB, van Gemert WG. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg 2008; 32 (03) 445-453
  • 8 Leppäniemi A. The hostile abdomen—a systematic approach to a complex problem. Scand J Surg 2008; 97 (03) 218-219
  • 9 Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg 1983; 7 (04) 481-488
  • 10 Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg 2010; 252 (02) 325-329
  • 11 Martinez JL, Bosco-Garate I, Souza-Gallardo LM. et al. Effect of preoperative administration of oral arginine and glutamine in patients with enterocutaneous fistula submitted to definitive surgery: a prospective randomized trial. J Gastrointest Surg 2020; 24 (02) 426-434
  • 12 Fiorindi C, Cuffaro F, Piemonte G. et al. Effect of long-lasting nutritional prehabilitation on postoperative outcome in elective surgery for IBD. Clin Nutr 2021; 40 (03) 928-935
  • 13 Huang W, Tang Y, Nong L, Sun Y. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: a meta-analysis of observational studies. J Crohn's Colitis 2015; 9 (03) 293-301
  • 14 Allocca M, Gilardi D, Fiorino G, Furfaro F, Peyrin-Biroulet L, Danese S. Sexual and reproductive issues and inflammatory bowel disease: a neglected topic in men. Eur J Gastroenterol Hepatol 2018; 30 (03) 316-322
  • 15 Hor T, Lefevre JH, Shields C, Chafai N, Tiret E, Parc Y. Female sexual function and fertility after ileal pouch-anal anastomosis. Int J Colorectal Dis 2016; 31 (03) 593-601
  • 16 Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ. Dutch Snapshot Research Group. Anastomotic leakage and chronic presacral sinus formation after low anterior resection: results from a large cross-sectional study. Ann Surg 2017; 266 (05) 870-877
  • 17 Fazio VW. Colon and Rectal Surgery. In: Walsh CJ, Jamieson NV, Fazio VW. eds. Top Tips in Gastrointestinal Surgery. London: Blackwell Science Ltd; 1999
  • 18 Benson AB, Venook AP, Al-Hawary MM. et al. NCCN Guidelines Insights: Rectal Cancer, Version 6.2020. J Natl Compr Canc Netw 2020; 18 (07) 806-815
  • 19 Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 2012; 255 (06) 1060-1068
  • 20 Daniels SL, Lee MJ, George J. et al. Prehabilitation in Elective Abdominal Cancer Surgery in Older Patients: Systematic Review and Meta-Analysis. BJS Open 2020; 4 (06) 1022-1041
  • 21 Christensen MA, Gaitanidis A, Parks J. et al. Thirty-day outcomes in the operative management of intestinal-cutaneous fistulas: a NSQIP analysis. Am J Surg 2021; 221 (05) 1050-1055
  • 22 Schwartzberg DM, Esen E, Remzi FH. Thoughtful ileostomy creation in patients undergoing redo IPAA. Dis Colon Rectum 2020; 63 (01) 117-120
  • 23 Brooke J, El-Ghaname A, Napier K, Sommerey L. Executive summary: Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) nursing best practice recommendations: enterocutaneous fistula and enteroatmospheric fistula. J Wound Ostomy Continence Nurs 2019; 46 (04) 306-308
  • 24 Fazio VW. Retractors and exposure in the pelvis. In: Walsh CJ, Jamieson NV, Fazio VW. eds. Top Tips in Gastrointestinal Surgery. London: Blackwell Science Ltd; 1999
  • 25 Latifi R, Gustafson M. Abdominal wall reconstruction in patients with enterocutaneous fistulas. Eur J Trauma Emerg Surg 2011; 37 (03) 241-250
  • 26 Leppäniemi A. Open abdomen for the management of catastrophic abdomen: evidence and controversies. Cir Esp (Engl Ed) 2020; (e-pub ahead of print) DOI: 10.1016/j.ciresp.2020.06.011.
  • 27 Aydinli HH, Peirce C, Aytac E, Remzi FH. A novel closure technique for complex abdominal wounds. Dis Colon Rectum 2018; 61 (04) 521-526
  • 28 van der Wal JB, Iordens GI, Vrijland WW, van Veen RN, Lange J, Jeekel J. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg 2011; 253 (06) 1118-1121
  • 29 Fazio VW, Cohen Z, Fleshman JW. et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection. Dis Colon Rectum 2006; 49 (01) 1-11
  • 30 Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH. ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001; 88 (11) 1533-1538
  • 31 Fragkos KC, Sebepos-Rogers G, Rahman F. When is parenteral nutrition indicated in the hospitalized, acutely ill patient?. Curr Opin Gastroenterol 2020; 36 (02) 129-135
  • 32 Sahai A, Bélair M, Gianfelice D, Coté S, Gratton J, Lahaie R. Percutaneous drainage of intra-abdominal abscesses in Crohn's disease: short and long-term outcome. Am J Gastroenterol 1997; 92 (02) 275-278
  • 33 Dale VH. The impact of perioperative music on abdominal surgery patients' experience of postoperative pain: a systematic review and meta-analysis. J Perioper Pract 2021; 31 (1-2): 31-43