Complex abdomen: proposal of a preliminary conceptual framework, clinical implications, and contemporary perspectivesABSTRACT
Introduction: The open abdomen has become a cornerstone in the care of critically ill patients undergoing damage control surgery, with severe abdominal sepsis, or at risk of abdominal compartment syndrome. These patients frequently develop a multidimensional clinical course - persistent infection, organ failure, loss of abdominal wall integrity, nutritional depletion, and entero-atmospheric fistulas - whose severity appears to emerge from the dynamic interaction among these factors rather than from visceral exposure alone. Current classifications, notably Björck’s amended classification, describe the anatomical progression of the open abdomen but do not integrate the physiological, infectious, nutritional, and organizational dimensions of care. The aim is to propose the term “complex abdomen” as a preliminary conceptual framework complementary to - and not a replacement for - existing classifications.
Methods: Conceptual scientific communication grounded in a narrative review of the literature (MEDLINE/PubMed, Embase, Cochrane Library, SciELO, and LILACS; 2000 to 2025; Portuguese, English, and Spanish), reported according to the SANRA scale. The synthesis followed best-fit framework synthesis, with the Cumulative Complexity Model as the a priori framework.
Results: Five constitutive domains are proposed - physiological instability; uncontrolled intra-abdominal infection; loss of abdominal wall domain; entero-atmospheric or complex enteric fistula; nutritional and intestinal failure - together with their associated cut-offs, a contextual organizational modifier recorded separately, and the criterion of simultaneous involvement of two or more domains. The domains, the cut-offs, and the criterion were proposed by the authors on the basis of the literature and clinical experience, without formal consensus and without empirical validation. The construct is presented as a dynamic clinical phenotype assessed at defined time points, not as an obligatory evolutionary stage or a prognostic score.
Conclusion: This is a preliminary framework rather than a validated definition. Formalizing this phenotype may improve clinical reasoning, multidisciplinary communication, and the selection of more homogeneous study populations. A three-step validation agenda - modified Delphi consensus, reliability and content validity assessment, and prospective prognostic testing within a multicenter registry - is proposed, together with explicit refutation criteria.
Keywords:
Open Abdomen; Intestinal Fistula; Damage Control Surgery; Intraabdominal Infections; Terminology as Topic
RESUMO
Introdução: O abdome aberto é estratégia fundamental no cuidado de pacientes críticos submetidos a cirurgia de controle de danos, com sepse abdominal grave ou em risco de síndrome compartimental abdominal. Esses pacientes frequentemente evoluem com alterações fisiopatológicas multidimensionais - infecção persistente, falência orgânica, perda da integridade da parede abdominal, déficit nutricional e fístulas enteroatmosféricas - cuja gravidade parece emergir da interação dinâmica entre esses fatores, e não da exposição visceral isolada. As classificações vigentes, notadamente a classificação revisada de Björck, descrevem a progressão anatômica do abdome aberto, mas não integram as dimensões fisiológica, infecciosa, nutricional e organizacional do cuidado. O objetivo é propor o termo “abdome complexo” como marco conceitual preliminar e complementar - e não substitutivo - às classificações existentes.
Métodos: Comunicação científica de natureza conceitual, fundamentada em revisão narrativa da literatura (MEDLINE/PubMed, Embase, Cochrane Library, SciELO e LILACS; 2000 a 2025; português, inglês e espanhol), relatada segundo a escala SANRA. A síntese seguiu a best-fit framework synthesis, com o Cumulative Complexity Model como referencial a priori.
Resultados: São propostos cinco domínios constitutivos - instabilidade fisiológica; infecção intra-abdominal não controlada; perda de domínio parietal; fístula enteroatmosférica ou enteral complexa; falência nutricional e intestinal -, os pontos de corte a eles associados, um modificador contextual organizacional registrado separadamente e o critério de comprometimento simultâneo de dois ou mais domínios. Domínios, pontos de corte e critério foram propostos pelos autores a partir da literatura e da experiência clínica, sem consenso formal e sem validação empírica. O construto é apresentado como fenótipo clínico dinâmico, avaliado em momentos definidos, e não como estágio evolutivo obrigatório ou escore prognóstico.
Conclusão: Trata-se de marco preliminar, e não de definição validada. A formalização desse fenótipo pode aprimorar o raciocínio clínico, a comunicação multidisciplinar e a seleção de populações mais homogêneas em pesquisa. Propõe-se agenda de validação em três etapas - consenso Delphi modificado, avaliação de confiabilidade e validade de conteúdo e teste prognóstico prospectivo em registro multicêntrico -, acompanhada de critérios explícitos de refutação.
Palavras-chave:
Abdome Aberto; Fístula Intestinal; Cirurgia de Controle de Danos; Infecções Intra-Abdominais; Terminologia como Assunto
INTRODUCTION
The open abdomen was initially described as a temporary strategy intended to reduce mortality in the setting of abdominal catastrophe, particularly in the context of damage control surgery1,2. Over time, its use expanded to the management of severe abdominal sepsis and of intra-abdominal hypertension and abdominal compartment syndrome3-5. Prolonged maintenance of the open cavity, however, is associated with high morbidity, including persistent infection, progressive difficulty in achieving fascial closure, and metabolic failure3,4.
Advances such as negative-pressure wound therapy and progressive fascial traction techniques have contributed to better closure rates and to a shorter duration of visceral exposure6-8. Even so, a substantial proportion of patients develop severe complications, notably entero-atmospheric fistulas (EAF), which are considered among the most challenging scenarios in contemporary abdominal surgery9-11.
To standardize the description of this condition, the Björck classification - proposed in 2009 and amended in 2016 - stratifies the open abdomen into four grades according to the degree of visceral adherence and fixation and the presence of contamination or fistula12,13. It is a well-established instrument, useful in both research and teaching17, and its strength lies precisely in what it sets out to do: to describe the anatomical progression of the abdominal wall-viscera interface. There is, however, a mismatch between the available terminology and the actual complexity of the clinical problem, since the abdominal wall axis is only one of the dimensions that determine the patient’s trajectory.
The terminology currently used to name these scenarios is, moreover, heterogeneous. Expressions such as complex abdomen, complex open abdomen, complex septic open abdomen, hostile abdomen, frozen abdomen, and complex abdominal wall circulate in the literature with variable meanings and, in most instances, without an explicit operational definition (Table 1). The best-delineated exceptions are complex abdominal wall, for which criteria have been established by expert consensus14, and loss of domain, defined by an international Delphi consensus15 - both, however, anchored in the elective setting of abdominal wall reconstruction rather than in the critically ill patient with an open abdomen. The remaining expressions are used adjectivally, often to describe a specific technical difficulty16. None of them was conceived to name, in an integrated and longitudinal fashion, the multidimensional clinical state discussed here. We recognize that introducing yet another term carries the risk of terminological proliferation; it is precisely for this reason that the present proposal is explicitly presented as preliminary and submitted to a formal pathway of consensus and validation (see “Educational implications, validation agenda, and refutation criteria”).
Related terms used in the literature, their definitional status, and their relationship to the proposal. The first four rows describe terms from the acute setting; the last two, from the elective setting of abdominal wall reconstruction. The proposal presented here differs from all of them in naming a multidimensional and longitudinal clinical phenotype rather than an anatomical finding or a technical difficulty.
In view of this gap, this manuscript proposes and structures the concept of “complex abdomen” as an integrative framework, complementary to current classifications. The specific objectives are: (i) to justify the need for an integrative term in light of the existing terminology; (ii) to provide a theoretical foundation for the notion of complexity applied to this setting and to make explicit how that theory supports - and limits - the proposed classification rule; and (iii) to offer a preliminary and explicitly provisional set of operational criteria, formulated so that it can be submitted to formal consensus, to reliability testing, and to prognostic validation.
METHODS
Design
This is a scientific communication of a conceptual nature, grounded in a narrative review of the literature and intended to propose and structure a terminological construct. It is neither a systematic review nor a study with primary data; consequently, no meta-analysis, formal risk-of-bias assessment, or assessment of the certainty of the evidence was performed. Reporting follows the quality domains recommended for narrative reviews by the SANRA scale18, with the aim of making the search, selection, and synthesis steps transparent. Because it does not involve human subjects or identifiable data, the study did not require review by a Research Ethics Committee.
Information sources and search strategy
MEDLINE/PubMed, Embase, the Cochrane Library, SciELO, and LILACS were searched, covering publications from January 1, 2000, to December 31, 2025, in Portuguese, English, and Spanish. The full strategy applied to PubMed is reproduced in Box 1; in the remaining databases, the same conceptual blocks were adapted to the corresponding syntax. Hand-searching of the reference lists of the included documents and of the pertinent international guidelines was also performed.
Eligibility and selection
Original articles, reviews, guidelines, consensus documents, and book chapters addressing the definition, classification, management, outcomes, or costs of the open abdomen and its complications, as well as theoretical frameworks on clinical and organizational complexity, were considered eligible. Isolated case reports without conceptual contribution, conference abstracts, and materials not subjected to editorial review were excluded.
The search was conducted in an exploratory and iterative manner, as is proper to narrative synthesis: the authors did not perform formal sequential screening with independent dual review and, for this reason, we do not report a numerical selection flow, which could only be reconstructed a posteriori. The full strategy is presented in Box 1 to allow the search to be reproduced by third parties, and the documents supporting each domain are cited by name in Table 2, so that the basis of the proposal is traceable even though the process was not systematic.
Constitutive domains, provisional operational criteria, nature of the items, and reference basis. All cut-offs are provisional and were imported from well-established definitions in adjacent domains; none has been validated in this specific population. Serum albumin was deliberately excluded from the nutritional domain because, in this setting, it behaves as a marker of inflammation 28 .
Synthesis and construction of the domains
The synthesis followed the logic of best-fit framework synthesis19, in which a pre-existing theoretical framework is used as the initial coding structure and is subsequently modified by the findings. The Cumulative Complexity Model20 was adopted as the a priori framework; it conceptualizes complexity as a dynamic imbalance between the burden imposed on the patient and on the system and the capacity to respond to it. From the included documents, the clinical dimensions repeatedly associated with adverse outcomes in the open abdomen were extracted; these dimensions were grouped thematically and retained as a domain when they satisfied four conditions: (a) recurrence in the retrieved literature; (b) measurability from routinely recorded clinical data; (c) non-redundancy with respect to the anatomical axis already staged by the Björck classification; and (d) biological plausibility of interaction with at least one other domain.
The origin of the result must be stated explicitly: the domains did not derive from a formal consensus process. They correspond to a thematic synthesis conducted by the three authors, informed by the retrieved literature and by clinical experience accumulated in referral centers for emergency and trauma surgery. The cut-offs presented in Table 2 were, in turn, imported from well-established definitions in adjacent domains (sepsis, organ dysfunction, intestinal failure, malnutrition, loss of abdominal wall domain) and have not been validated in this specific population. This origin and this limitation are acknowledged throughout the manuscript and determine the status of the proposal.
Origin and status of the criterion of two or more domains
The threshold of two or more domains is pragmatic and unvalidated; its justification is conceptual, not empirical. In the classic distinction between what is complicated and what is complex, a problem confined to a single dimension - however severe - remains, in principle, decomposable and amenable to sequential treatment; complexity emerges when at least two dimensions interact and feedback on each other21,22. A parsimony argument may be added: a single-domain criterion would render the construct redundant with respect to instruments that are already available and better validated - the Björck classification for the anatomical axis, the SOFA score for organ dysfunction, and the GLIM criteria for nutritional status. Alternative thresholds are equally defensible, among them a requirement of three or more domains, differential weighting among domains, and a requirement of persistence over a longer period; all of these should be formally tested in the consensus step described in “Educational implications, validation agenda, and refutation criteria”.
Existing terminology and the limits of current classifications
The Björck classification organizes the open abdomen into four grades: grade 1 (no adherence or fixation, subdivided into 1A clean, 1B contaminated, and 1C with enteric leak), grade 2 (developing fixation, 2A/2B/2C), grade 3 (frozen abdomen, 3A/3B), and grade 4 (established entero-atmospheric fistula)12,13. Its virtue - the precise description of a single axis - at the same time delimits its scope. By construction, it is an essentially unidimensional staging instrument centered on the abdominal wall-viscera interface; it was not conceived to capture, nor does it purport to capture, physiological instability, persistent sepsis, nutritional status, or resource use. Two patients classified as grade 2B may follow radically different trajectories depending on the presence and the interaction of these other dimensions - variability that multicenter open abdomen registries have been documenting17.
Table 1 summarizes the related terms available, their predominant use, the presence or absence of a formal operational definition, and their relationship to the proposal presented here. Three observations emerge from this terminological review. First, the terms with a formal definition - complex abdominal wall14 and loss of domain15 - refer to the elective setting of abdominal wall reconstruction and were built through structured consensus processes, a methodological precedent that the present proposal recognizes as the appropriate path. Second, the expressions used in the acute setting (hostile abdomen, frozen abdomen, complex septic open abdomen) describe intraoperative findings or a specific technical difficulty, not the longitudinal state of the patient. Third, and decisive for the originality of the proposal: none of the existing terms defines a multidimensional clinical phenotype that can be assessed over time and is explicitly articulated with the anatomical axis already staged.
It is at this point that an integrative term is justified. The “complex abdomen” is neither a new scale competing with Björck’s nor a replacement for it: it names the multidimensional clinical state in which the open abdomen - staged by Björck - is only one of the axes. Three complementary conceptual levels are thus distinguished: the open abdomen (the anatomical condition), the Björck grade (the staging of that condition), and the complex abdomen (the multidimensional clinical phenotype that encompasses them).
Theoretical foundation: from coexistence to interaction
The concept of complexity employed here is not rhetorical; it is anchored in an established body of theory. Medicine, heir to the reductionist method, describes linear systems well - systems in which the whole equals the sum of its parts21,22. Complex systems, by contrast, are characterized by interdependence among components, nonlinearity, dynamic feedback, context sensitivity, and emergence - properties of the whole that cannot be explained by examining the parts in isolation21. In critical care medicine, this framework is already used to describe the pathophysiology of sepsis and multiple organ dysfunction22, and models of patient complexity conceptualize it as a dynamic imbalance between burden and capacity, with feedback loops that change over time20.
It is necessary, however, to address a legitimate objection head-on: the mere coexistence of two domains does not demonstrate interaction, feedback, or emergent behavior. Theory grounds the expectation of interaction, not its verification. The criterion of two or more domains must therefore be understood as an observable entry condition - necessary but not sufficient - for a phenotype whose emergent nature remains hypothetical until it is tested. Three plausible feedback loops, supported by known pathophysiology, make the hypothesis verifiable and are depicted in Figure 1: (i) persistent sepsis → hypercatabolism and malnutrition → fascial retraction and impaired healing → inability to close → prolonged visceral exposure → new infection; (ii) entero-atmospheric fistula → effluent loss and local contamination → sepsis and nutritional depletion → lower likelihood of closure and reconstruction → perpetuation of the fistula; (iii) volume resuscitation and visceral edema → loss of domain → multiple reoperations → iatrogenic bowel injury and new fistula.
Preliminary conceptual model of the complex abdomen. The five constitutive domains, their respective provisional operational criteria, and the classification criterion (open abdomen combined with two or more simultaneous domains, sustained for at least 24 hours) are presented together with the contextual modifier, which is recorded separately and not counted toward the classification. The highlighted boxes correspond to the anatomical axis, staged by the Björck classification (grades 3 and 4) 12,13 , which is here incorporated into the construct and not replaced by it. The dashed arrows represent hypothetical feedback loops among domains, formulated as testable hypotheses (see “Theoretical foundation: from coexistence to interaction”). The model is hypothetical: domains, cut-offs, and the classification criterion were proposed by the authors, without formal consensus and without empirical validation.
Two consequences follow from this reasoning. The first is methodological: the claim of emergence is empirically testable and must be tested through interaction terms and mediation analyses in prospective data, rather than assumed (see “Educational implications, validation agenda, and refutation criteria”). The second is conceptual, and it should be stated without ambiguity: the complex abdomen is proposed as a dynamic clinical phenotype - a state of the patient at a given moment, subject to reassessment and partially reversible. It is not an evolutionary stage, since it presupposes neither an obligatory sequence nor a unidirectional progression among domains; and it is not a prognostic score, since no predictive capacity is attributed to it before validation. Any prognostic value of the construct is a hypothesis to be tested, not a premise.
Preliminary definition and provisional operational criteria
The definition below is presented in a standardized form and reproduced consistently in the abstract, in Figure 1, and in Table 2, so as to eliminate any divergence among the different representations of the construct.
The five domains, their components, the proposed cut-offs, and the nature of each item are detailed in Table 2. The distinction regarding the nature of the items responds to a conceptual requirement: clinical determinants (physiological instability, uncontrolled infection, nutritional failure) describe active processes that can be modified by intervention; structural consequences (loss of abdominal wall domain, fistula) describe resulting anatomical states, largely irreversible during the index admission; and resource use describes the care cost generated by both. Conflating these categories would produce circularity - severity would be defined by its own effect.
For this reason, the organizational domain previously proposed has been removed from the set of constitutive criteria and reformulated as a contextual modifier. The rationale is straightforward: items such as the availability of a multidisciplinary team, the need for interhospital transfer, or access to a particular dressing device depend on the capacity of the institution and not on the patient; were they kept among the diagnostic criteria, the same patient would be classified differently depending on the hospital in which he or she was admitted. Resource use remains relevant - it is, indeed, one of the most measurable dimensions of the problem - and therefore continues to be recorded, but as contextual information, comparable across institutions and amenable to separate analysis.
As to application notes, three points deserve mention. First, serum albumin is not part of the nutritional domain, since it behaves as a negative acute-phase protein and in this setting reflects primarily inflammation28. Second, the physiological cut-offs were deliberately anchored in already established definitions (Sepsis-323 and SOFA24), so as to avoid creating novel, untested thresholds. Third, measurement of the interfascial distance must be standardized as to timing (at the end of the laparotomy, under muscle relaxation) and method (sterile ruler or computed tomography), an item that will necessarily be part of the consensus step.
Assessment is repeated at each planned relaparotomy and, in the absence of one, at least every 48 hours, recording which domains are involved at each time point. The complex abdomen state is considered resolved when fewer than two domains remain involved for at least 48 consecutive hours. The statement that a patient may “enter and leave” the category must, however, be qualified: reversibility is asymmetric across domains. Physiological instability, infection, and nutritional failure are potentially reversible during the index admission, whereas loss of domain, frozen abdomen, and entero-atmospheric fistula rarely resolve before definitive reconstruction, which is often performed months later. In practice, therefore, exit from the category almost always occurs through resolution of domains 1, 2, and 5, and the trajectory of the structural domains tends to be monotonic throughout the admission.
Relationship to the Björck classification
Table 3 contrasts the two terms with respect to their object, the nature of the construct, current validation status, purpose, and limitations. It is worth emphasizing that the relationship between them is one of nesting and not of competition: domains 3 and 4 correspond, respectively, to grades 3 and 4 of the Björck classification, so that anatomical staging is fully preserved and comes to function as one of the components of the phenotype. A patient may thus be described completely and without redundancy as, for example, “open abdomen Björck 2B, complex abdomen owing to involvement of domains 1, 2, and 5, with contextual modifier present.” This notation preserves the well-established anatomical information and adds the multidimensional information that the proposal seeks to formalize.
Clinical, organizational, and economic implications
Recent literature emphasizes the importance of specialized centers and of institutional protocols in the management of the complicated open abdomen3,4. Placing these patients within an explicit construct may facilitate the creation of specific care pathways, quality audits, and the early recognition of high-risk scenarios, and may also render resource use and outcomes comparable across institutions.
The economic dimension illustrates the systemic burden of this condition well, even though the available data are limited. A United States analysis estimated a daily cost of US$94 to US$111 for commercial negative-pressure wound therapy, as against approximately US$4 per day for the alternative of gauze under suction, plus approximately US$20 in labor per dressing change33. Three caveats are indispensable. First, this is an isolated estimate restricted to the cost of the dressing, which does not incorporate intensive care unit days, reoperations, prolonged parenteral nutrition, or delayed reconstruction - components that plausibly exceed the cost of the device by a wide margin. Second, the figures derive from a single health care system and from a price structure that is not transferable to Brazil or to other middle-income countries, in which the availability of the commercial device, reimbursement mechanisms, and labor costs differ substantially. Third, no cost studies dedicated to the open abdomen conducted in the Latin American context were identified in the retrieved literature - a relevant gap that formalization and systematic recording of the contextual modifier could help to address. For these reasons, the economic data are presented here as an illustration of the care burden and not as a quantification of the construct.
The development of entero-atmospheric fistulas is a paradigmatic example of this interweaving of dimensions, being associated with high morbidity, prolonged hospitalization, and a substantial impact on quality of life30-32. Contemporary strategies for effluent isolation, local control, and delayed reconstruction9-11,16,31 reinforce the need for a longitudinal view of the problem that goes beyond the anatomical description of the open abdomen.
Educational implications, validation agenda, and refutation criteria
From an educational standpoint, a more comprehensive nomenclature may favor the early recognition of high-risk scenarios and longitudinal care planning by multiprofessional teams, especially in institutions with a lower volume of such cases.
From a scientific standpoint, the proposal will acquire value only if it is subjected to verification. To that end, a three-step agenda is proposed:
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Formal consensus. A modified Delphi study, with an international and multiprofessional panel, designed to select the domains, define the cut-offs, and compare alternative thresholds (two versus three domains; differential weighting; minimum duration), reported according to the methodological criteria recommended for consensus studies34 and following the precedent already established for related terms in abdominal wall surgery14,15.
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Reliability and content validity. Retrospective application to multicenter cohorts, with measurement of interobserver agreement and, in particular, assessment of the proportion of patients classified differently across institutions - a direct test of the robustness of the construct to variation in institutional capacity.
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Prognostic validation. Prospective application within a multicenter registry, such as the International Register of Open Abdomen17, to determine whether the construct adds prognostic discrimination to the Björck classification combined with organ dysfunction scores, and whether interaction terms among domains contribute beyond additive effects.
Finally, the criteria that would refute the proposal should be stated. It should be considered unsupported if: (i) interobserver agreement is low, indicating that the criteria cannot be applied reproducibly; (ii) the construct adds no prognostic information to instruments already available, thereby becoming redundant; or (iii) interaction terms among domains prove not to be relevant, in which case the coexistence of domains would represent a mere summation of severities - and not complexity in the theoretical sense adopted here.
Limitations
The main limitation is the status of the construct itself. The domains, the cut-offs, and the criterion of two or more domains were proposed by the authors on the basis of a narrative review and clinical experience, without a formal consensus process and without any empirical validation; no diagnostic or prognostic capacity is attributed to it at this time. The cut-offs were imported from well-established definitions in adjacent domains and have not been tested in this specific population, in which they may behave differently. The review is narrative and therefore subject to non-systematic selection of the literature: the search was exploratory and iterative, without formal sequential screening with independent dual review, which entails a risk of selection and confirmation bias and precludes the presentation of a numerical selection flow. The bibliographic base, although expanded, remains limited for a proposal of terminological scope. There also remains a risk of terminological proliferation, mitigated - but not eliminated - by the review of related terms presented in Table 1 and by the explicit commitment to a formal consensus pathway. Finally, the available economic data are scarce and restricted to a single health care system, and the figure presented is a hypothetical model, not a result.
Final considerations
Recognizing the open abdomen as part of a broader clinical state more faithfully reflects the reality of contemporary surgical practice. Structured as a preliminary conceptual framework - with an explicit theoretical foundation, provisional operational criteria, clear delimitation with respect to already existing terms, and a validation agenda with refutation criteria - the term “complex abdomen” seeks to contribute to interdisciplinary communication, care planning, and the design of more homogeneous studies, in a manner complementary to and not a substitute for current models. Its clinical or scientific adoption, however, should not precede the formal consensus and empirical validation proposed here: it is as a structured hypothesis, and not as an established definition, that the proposal is presented for discussion by the surgical community.
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