Access, equity, and innovation in the management of the open abdomen: the lack of proper treatment and the impact in low-income populations.

Abstract

The open abdomen (OA) has evolved from a wartime necessity into a core component of damage control surgery and of the management of complex abdominal disease, and now also encompasses abdominal compartment syndrome and severe gastrointestinal complications. Negative pressure therapy (NPT) and, more recently, fascial traction adjuncts have transformed outcomes in high-income settings, but access remains profoundly unequal, and that inequality translates into morbidity and mortality driven not by disease severity, but by the inability to meet a minimum standard of care. That inequality is now measurable. In the International Register of Open Abdomen, definitive abdominal closure was achieved in 82.3% of patients in the Americas against 56.4% in Asia, with mortality of 31.9%, 51.6% and 56.9% in the American, European, and Asian continents, and commercial NPT used in 77.4% of American patients against a Barker vacuum pack in 48.2% of Asian patients. This article proposes an agenda for closing that gap. It reviews temporary abdominal closure from the Borraez (Bogota) bag and the Barker vacuum pack to commercial NPT, and the fascial traction adjuncts that most strongly analyze primary fascial closure, pairing each with its approximate cost and feasibility in a resource-constrained hospital. Four proposals follow: a resource-stratified standard of care defining a minimum acceptable package at three tiers of institutional capability; a formal evaluation program for locally assembled, low-cost negative pressure systems applied to the laparostomy; prioritization of fascial traction, the cheapest and most transferable element of contemporary care, as the first upgrade where commercial NPT is unaffordable; and an industry, regulatory, and society agenda covering serviceable reusable devices, tiered pricing, essential-device listing, and a registry reaching beyond the academic centers now contributing data. Closing this gap is an engineering, regulatory, and research problem as much as a clinical one, and it is solvable.