Low-cost dynamic fascial traction using serial Bogota bag tightening in open abdomen management: A prospective randomized study

Abstract

BACKGROUND

Management of the open abdomen (OA) remains challenging, particularly in low-resource settings. Dynamic fascial traction (DFT) has been shown to improve abdominal wall approximation and reduce morbidity; however, most available techniques are expensive, resource intensive, and supported largely by retrospective data, predominantly in trauma populations.

AIM

To evaluate the feasibility, safety, and effectiveness of a low-cost DFT technique using serial Bogota bag tightening in patients with an OA, and to compare its impact on time to abdominal wall approximation and hospital stay with conventional non-traction laparostomy management.

METHODS

This prospective randomized study was conducted at a tertiary-care teaching hospital in North India between April 2023 and June 2024. Adult patients (> 18 years) with complete abdominal dehiscence following emergency laparotomy requiring a laparostomy bag were enrolled. Patients with enterocutaneous or entero-atmospheric fistulae were excluded. Participants were randomized into two groups: A control group managed with a standard laparostomy bag without traction, and a study group in which DFT was achieved by serial tightening of a simple Bogota bag. The primary outcome was the time required to achieve a skin-to-skin distance (SSD) of 5 cm. Secondary outcomes included hospital stay, postoperative nutritional parameters, complications, and mortality.

RESULTS

A total of 36 patients were randomized equally into the two groups. Baseline demographic, clinical, and laboratory characteristics were comparable. Abdominal tuberculosis and enteric fever were the most common aetiologies. The study group achieved a significantly shorter time to an SSD of 5 cm compared with controls (9.94 ± 1.88 days vs 13.0 ± 2.87 days; P = 0.0003), along with a significantly reduced hospital stay (17.0 ± 1.85 days vs 20.39 ± 3.17 days; P = 0.0013). There were no significant differences between groups in postoperative complications, nutritional outcomes, or mortality.

CONCLUSION

Serial tightening of a simple Bogota bag is a feasible, safe, and inexpensive method for achieving DFT in patients with an OA. This bedside technique significantly accelerates abdominal wall approximation and shortens hospital stay without increasing morbidity, making it particularly suitable for resource-limited settings. Larger multicentre studies are required to validate long-term outcomes and definitive fascial closure rates.

Key Words: Open abdomen; Dynamic fascial traction; Bogota bag; Emergency laparotomy; Abdominal wall closure

Core Tip: Dynamic fascial traction (DFT) improves outcomes in open abdomen management but is often limited by cost and resource requirements. This prospective randomized study demonstrates that serial tightening of a simple Bogota bag provides an effective, bedside, and low-cost alternative for achieving DFT, significantly reducing time to abdominal wall approximation and hospital stay without added complications-an approach particularly relevant to low- and middle-income healthcare settings.

INTRODUCTION

Peritonitis and trauma constitute the most common causes of emergency laparotomy (EL) in India. These patients often present late to tertiary-care hospitals, resulting in high mortality (up to 30%) and significant morbidity[1]. Abdominal dehiscence is a frequent postoperative complication, reported in 25% to 30% of cases, and can lead to prolonged hospitalization and increased healthcare costs. The use of an open abdomen (OA) following EL has therefore emerged as a necessary technique for the prevention and management of ongoing abdominal sepsis, abdominal compartment syndrome (ACS), vascular emergencies, bowel ischemia requiring second-look laparotomy, and abdominal cocoon secondary to tuberculosis. Traditional OA techniques do not involve temporary closure of either the skin or the fascia[2].

The literature on the OA dates back to 1897; however, it remained sparse until the advent of damage control surgery (DCS) in the 1990s. The term “damage control” was first coined by Rotondo and Zonies[3] in 1993. Further evolution of the OA concept followed recognition of ACS and the use of OA for the treatment of ACS, as described by Kron et al[4] in 1984. Subsequently, the World Society of the ACS published guidelines for the management of ACS, which are now followed worldwide. At present, the use of OA is well established in the management of trauma, severe acute pancreatitis, difficult intra-abdominal sepsis, mesenteric ischemia, and vascular emergencies. This approach allows abbreviation of the initial surgical procedure as part of DCS, facilitates adequate lavage and drainage, enables planned re-look procedures, and helps prevent and treat ACS[5]. However, postoperative management of the OA is associated with several challenges, including excessive fluid and electrolyte losses, organ dysfunction, bowel evisceration, increased risk of enterocutaneous fistula (ECF) and entero-atmospheric fistula (EAF), delayed wound healing, and subsequent development of unsightly scars and ventral hernia[2,6].

Considerable efforts have been made in the surgical literature to develop methods that either provide temporary coverage of the OA or promote accelerated wound healing. Temporary abdominal closure (TAC), once regarded as a last-resort option, has now become the standard of care in selected clinical scenarios such as acidosis, coagulopathy, and hypothermia. TAC techniques range from the simple plastic Bogota bag to absorbable or non-absorbable mesh closures. These methods may be combined with dynamic fascial traction (DFT) and negative wound pressure (vacuum) therapy (NWPT) to facilitate gradual approximation of the abdominal wall and staged closure[7]. These techniques are based on the biological property of human cells and tissues to undergo expansion when subjected to sustained mechanical stress[8]. Despite these advances, no single technique has emerged as the definitive standard, with reported success rates for primary closure approaching, but rarely exceeding, 80%[2,7,9]. Although NWPT-based techniques have shown the most promising outcomes, they are expensive, require repeated operating room interventions, and are cumbersome to apply, particularly in low-resource settings such as our institution, which is a government-funded hospital providing free care to a large socioeconomically disadvantaged population.

We have routinely used a Bogota-type laparostomy bag fashioned from an opened urine collection plastic bag for several years. By applying serial tightening of the bag using simple sutures, we attempted to achieve DFT with the aim of enhancing wound healing and facilitating abdominal wall approximation. The design of the present study was prospective and comparative, in order to minimize confounding bias.

Unlike previously described mesh-mediated or vacuum-assisted traction systems, our technique provides continuous DFT using a simple Bogota bag without the need for negative pressure devices, mesh fixation, or repeated operating room interventions. To our knowledge, this represents one of the few prospective randomized studies evaluating a purely bedside, low-cost DFT method in a predominantly septic patient population.

MATERIALS AND METHODS

A prospective randomized study was conducted in the Department of Surgery of our teaching tertiary-care institute in North India between 1 April 2023 and 30 June 2024. After obtaining due approvals from the Institutional Review Board and the Institutional Ethics Committee [F.No. TP (MD/MS) (28/2022)/IEC/ABVIMS/RMLH/1194] dated 13 March 2023, and in accordance with the Declaration of Helsinki guidelines, all patients aged above 18 years with complete abdominal dehiscence following EL requiring application of a laparostomy bag were recruited for the study. Patients presenting with abdominal dehiscence in association with an ECF or EAF were excluded. Complete abdominal dehiscence was defined as full-length separation of the fascial edges with exposed intra-abdominal viscera, necessitating TAC using a laparostomy bag. This corresponds to Björck grade 2-3 OA and precludes safe primary fascial or skin closure at the index procedure.

Following enrolment and procurement of written informed consent, patients were randomized using computer-generated random number tables into two groups: Group 1 (control group), in which the laparostomy bag underwent no traction, and group 2 (study group), in which dynamic traction was applied to the laparostomy bag through serial tightening. Allocation concealment was ensured using the sealed envelope technique. Postoperative follow-up was conducted at 1 week, 2 weeks, and 6 weeks, with outcomes assessed using predefined parameters. Randomization resulted in a balanced etiological distribution between the groups, thereby minimizing disease-specific confounding.

Methodology

Patients presenting for EL were prepared as per standard institutional protocol. All relevant haematological, biochemical, and radiological investigations were performed, and the indication for EL was documented. Preoperative resuscitation was carried out according to standard guidelines. The indications for laparostomy were followed as per accepted guidelines[2,5] and these were communicated to the operating team prior to surgery. All procedures were performed by surgeons experienced with the technique employed in the study.

Application of laparostomy with dynamic traction

The laparostomy was fashioned using readily available, inexpensive materials, including plastic urine collection bags and polypropylene sutures. The urine collection bags were first split open to form a sheet approximately 30 cm × 25 cm in size and placed over the open wound to assess adequacy of coverage. If coverage was inadequate, two bags were used. After thorough lavage of the abdominal cavity, the single bag was fenestrated by creating 10-15 holes of approximately 2 cm diameter to facilitate drainage of intra-abdominal fluids. The bag was then sutured circumferentially to the skin margins using a continuous interlocking polypropylene No. 1 suture with a cutting needle, taking care to avoid tearing of the plastic material. In cases of extensive dehiscence, two bags were similarly sutured on opposite sides of the wound and overlapped in the midline.

The skin-to-skin distance (SSD) was measured transversely at its widest point following application of the initial laparostomy. The plastic bag was covered with generous amounts of absorbent gauze and secured over the abdomen using adhesive tapes. On postoperative day 3, the central portion of the plastic laparostomy bag (or the two free flaps when two bags were used) was elevated and sutured using additional silk or polypropylene sutures to generate stretch or traction at the wound edges. This process was repeated weekly until an SSD of 5 cm was achieved (Figure 1). The laparostomy bags were reapplied if torn, and the procedure could be performed under local lignocaine infiltration when required. No tightening of the Bogota bag was performed in the control group (Figure 2). Wound irrigation and suction were carried out as clinically indicated. Clinical, laboratory, and wound-related parameters were documented during the postoperative period.

Figure 1 Modified Bogota bag flap technique for dynamic fascial traction in open abdomen. A: The edges of an open abdominal wound sutured to two separate plastic Bogota bags (cut-open urine collecting bag) to create two flaps; B: The flaps are sutured in the center with continuous polypropylene or nylon sutures to create traction on the edges.

Figure 2 Challenging open abdomen after pancreatic necrosectomy with limited feasibility of dynamic fascial traction. A: An exceptionally difficult open abdomen following pancreatic necrosectomy; B: Two complete bags used after suturing them together; dynamic fascial traction (DFT) not feasible due to large domain loss; C: After 3 weeks of partial DFT, the skin gap is still significant and might need split skin grafting.

The primary outcome variable was the time required to achieve an SSD of 5 cm. A SSD of ≤ 5 cm was selected as it represents a widely accepted threshold beyond which delayed primary or definitive fascial closure (DFC) can be achieved without undue tension.

Statistical analysis

Following data collection in tabulated form, continuous variables were expressed as mean ± SD, while categorical variables were expressed as absolute n (%). Data normality was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Continuous variables were compared using the student’s t-test for parametric data or the Mann-Whitney U test for non-parametric data, whereas categorical variables were compared using the χ² test or Fisher’s exact test, as appropriate. Data analysis was performed using Microsoft Excel™ and SPSS™ software version 27.0.0.

All statistical tests were conducted with a 95% confidence interval, and a P value < 0.05 was considered statistically significant. Sample size calculation was based on a hypothesized effect size of 5 days (15 days vs 10 days), representing the expected difference in time to achieve an SSD of 5 cm between the two groups[6]. Assuming a power of 80% and a significance level of 0.05, the required sample size was calculated to be 18 patients per group, yielding a total sample size of 36 patients.

RESULTS

The demographic and clinical characteristics of the two study groups, comprising a total of 36 patients, are summarized in Table 1. Most patients belonged to the 40-50-year age group. The most common aetiologies necessitating EL were abdominal tuberculosis and enteric fever, accounting for 36% of cases each, while 14% of patients presented with a ruptured liver abscess. Diabetes mellitus was the most prevalent comorbidity and was present in 39% of patients. The two groups were well matched with respect to biochemical and laboratory parameters known to influence outcomes in sepsis, including liver function tests, serum creatinine, serum albumin, international normalized ratio, and viral markers.

Table 1 Demographic and clinical variables of 36 patients randomized into group 1 and group 2, n (%).

Variable	Group 1 (control or no traction; n = 18)	Group 2 (study group with dynamic traction on the laparostomy bag; n = 18)	P value
Mean age (years ± SD)	43.78 ± 11.66	41.61 ± 15.67	0.6410
Male:female ratio	1:1	4:5	1.000
Primary laparostomy creation	2 (11.11)	5 (27.78)	1.000
Needing re-application of laparostomy	3 (16.67)	6 (33.33)	1.000
Creation of stoma	13 (72.2)	10 (55.6)	1.000
Comorbidity
Hypertension	1 (5.56)	1 (5.56)	1.000
Diabetes mellitus	7 (38.89)	6 (33.33)
Chronic liver disease	1 (5.56)	0
Pulmonary disease	1 (5.56)	1 (5.56)
Etiology
Tuberculosis	6 (33.33)	6 (33.33)	0.76
Enteric fever	7 (38.89)	5 (27.78)
Trauma	1 (5.56)	3 (16.67)
Ruptured liver abscess	2 (11.11)	3 (16.67)
Others	2 (11.11)	1 (5.56)
Investigations
Abnormal liver function tests	8 (44.4)	10 (55.6)	0.74
Mean INR	1.65 ± 0.568	1.66 ± 0.486	0.915
Mean serum creatinine (mg/dL ± SD)	1.61 ± 0.624	1.61 ± 0.624	1.00
Mean serum albumin (g/dL ± SD)	2.80 ± 0.570	2.76 ± 0.534	0.829
Viral markers positive (HBsAg, HIV, HCV)	2 (11.11)	1 (5.56)	1.00
Mean blood transfusion units per patient	1.67	1.83	1.000
SOFA score > 9 at admission	4 (22.2)	4 (22.2)	1.000
Mean initial fascial gap (cm ± SD)	14.2 ± 2.3	15.1 ± 2.1	1.000

All continuous variables depicted in terms of mean ± SD; categorical variables depicted by number; difference in means was analyzed using t-test/Mann-Whitney U test, while difference in proportions was analyzed using χ² test/Fischer’s exact test. P values reported as 1.000 reflect identical distributions between groups when analyzed using Fisher’s exact test in the presence of small cell counts. INR: International normalized ratio; SOFA: Sequential organ failure assessment; HBsAg: Hepatitis B surface antigen; HIV: Human immunodeficiency virus; HCV: Hepatitis C virus.

In the majority of cases, the laparostomy bag was applied at the time of the index surgery when primary closure was considered unfeasible or technically difficult due to bowel or parietal wall oedema (primary laparostomy). In other patients, postoperative wound dehiscence or the development of ACS necessitated subsequent application of a laparostomy bag. Reapplication was required in several cases due to rupture of the initial laparostomy bag. The two groups were comparable with respect to these parameters, as well as in the distribution of intestinal stomas and sequential organ failure assessment scores at admission.

As shown in Table 2, the postoperative course was similar in both groups with regard to the time to initiation of oral intake, requirement for parenteral nutrition, incidence of complications, and mortality. However, patients in the study group achieved a SSD of 5 cm significantly earlier and consequently had a significantly shorter duration of hospital stay compared with the control group.

Table 2 Outcome parameters in 36 patients randomized into group 1 group 2.

Variable	Group 1 (control or no traction; n = 18)	Group 2 (study group with dynamic traction on the laparostomy bag; n = 18)	P value
Mean day of starting oral intake (± SD)	2.83 ± 1.20	2.83 ± 0.83	0.115
Mean days of TPN (± SD)	2.5 ± 1.89	2.89 ± 1.28	0.47
Mean days to achieve 5 cm skin-to-skin distance (± SD)	13 ± 2.87	9.94 ± 1.88	0.0003a
Mean hospital stay (days ± SD)	20.39 ± 3.17	17.0 ± 1.85	0.0013a
Mortality (%)	1 (5.56)	1 (5.56)	1.000
Follow-up rate at 6 weeks (%)	100	100	-
Follow-up rate at 3 months (%)	33	39	1.000
Incisional hernia at last follow-up	0	0	-

^aP < 0.05.

All continuous variables depicted in terms of mean ± SD; categorical variables depicted by n (%); difference in means analyzed using t-test, while difference in proportions analyzed using χ² test. TPN: Total parenteral nutrition.

DISCUSSION

In the present study, 36 patients randomized into two groups were well matched with respect to demographic and clinical parameters. Use of an inexpensive and simple bedside technique for DFT was associated with a significantly shorter hospital stay and a reduced time to achieve a skin-to-skin gap of 5 cm in the laparostomy wound. We also reviewed the available literature to assess the extrapolatability of our findings.

The most widely used classification of the OA was amended by Björck et al[10] in 2016 and includes four categories ranging from a clean wound with no adhesions to an established ECF with a frozen abdomen. Complex and high-grade OA s are associated with the poorest outcomes and require specialized management. Such patients were excluded from the present study to minimize confounding factors and allow more uniform assessment of the DFT technique. As noted earlier, the use of an OA is most commonly encountered in trauma, intra-abdominal sepsis, vascular emergencies, and severe acute pancreatitis. In our cohort, intra-abdominal sepsis-particularly abdominal tuberculosis-was the predominant indication.

While the indications for OA and DCS in trauma have been substantially standardized, as highlighted by Roberts et al[11] in a systematic review published in 2021, their application in septic patients remains less clearly defined. This is partly attributable to the relative paucity of data from developing countries, where intra-abdominal sepsis is frequently encountered. In such settings, abbreviated laparotomy may facilitate deferred intestinal anastomosis, reduce the risk of ACS secondary to visceral oedema, and allow planned re-exploration for improved source control and assessment of secondary intestinal ischemia. The closed or open after laparotomy for severe complicated intra-abdominal sepsis trial by Kirkpatrick et al[12] aims to compare OA management with DFT using NWPT in this patient population.

Techniques employed to expedite abdominal wound healing in the OA can be broadly classified into skin closure, patch closure, and vacuum-assisted closure methods[7,9,13-17]. Skin closure techniques using towel clips or monofilament sutures are relatively simple and widely feasible; however, they carry a risk of evisceration. In addition, towel clips may be unstable and interfere with bedside care and radiographic imaging. Patch closure techniques include use of the conventional Bogota bag, absorbable mesh (including biological mesh), or non-absorbable mesh. Although meshes are theoretically attractive due to their ability to permit fluid egress, promote rapid granulation, and reduce subsequent hernia formation, their use in emergency settings is often limited by infection. Mesh extrusion, fistulization, and sloughing of the fascia-particularly in the setting of severe sepsis-are well-recognized complications. Biological meshes are additionally limited by prohibitive cost and restricted availability.

The plastic sheet-derived Bogota bag remains inexpensive, readily available, and effective for safely covering exposed bowel while minimizing heat and fluid loss. It also facilitates re-exploration when required and has therefore been widely adopted over the past two decades. However, the conventional Bogota bag does not inherently promote wound “saucerization” or medial approximation of the abdominal wall, resulting in a higher incidence of domain loss and subsequent ventral hernia. Modifications proposed to address these limitations include the Wittmann patch, which employs opposing sheets with fascial hooks to provide a degree of DFT. Despite its efficacy, this remains a commercial product associated with high cost.

Vacuum-assisted closure techniques have also been extensively studied, particularly in trauma patients. Indigenous adaptations of negative pressure wound therapy (NPWT) using layered coverage of exposed bowel with perforated plastic sheets, absorbent sponges, and an external suction drain have demonstrated utility in large granulating wounds of the limbs and back following trauma or necrotizing soft tissue infections. The proposed mechanisms include effective removal of inflammatory cytokines and toxins, promotion of neovascularization, and enhanced neutrophil chemotaxis. However, in our experience, the application of NPWT in abdominal sepsis is complicated by the need for frequent dressing changes and an increased risk of ECF formation.

More recently, commercially available NPWT systems such as ABThera™ and ABRA™ (Abdominal Re-approximation Anchor) have been evaluated[7,9]. These hybrid systems combine NPWT with mesh-mediated or silicone elastomer-mediated fascial traction. Such techniques address a particularly challenging sequela of the OA, namely adhesion of bowel loops to the lateral peritoneal surfaces, which impedes effective wound “saucerization” and contributes to prolonged hospitalization and the eventual need for skin grafting or mesh repair. These systems involve placement of a plastic barrier over the bowel extending beneath the lateral abdominal wall to prevent adhesions. However, they are resource intensive, requiring repeated application two to three times weekly, preferably in the operating room, and necessitate a dedicated, trained multidisciplinary team. In specialized centres, these approaches have achieved primary fascial closure rates of 70%-80%, compared with 35%-45% reported with simple patch closures[9,14-17].

A recent systematic review by Lech et al[13], encompassing 535 patients, reported a complete fascial closure rate of 77.3%, overall mortality of 30.3%, mean OA treatment duration of 14.6 days, mean hospital stay of 43.3 days, EAF rate of 5.6%, and incisional hernia rate of 34.7%. However, the included studies were heterogeneous in design. These data underscore that, despite advanced and costly techniques, significant risks of fistula formation and ventral hernia persist. In low-resource settings with a high burden of septic patients, there is therefore a pressing need for a simple, bedside, and cost-effective solution.

Several innovative attempts to achieve DFT without the need for frequent operating room interventions have been described and are summarized in Table 3. Fasciotens™ has been increasingly utilized in patients with OA[6,18,19], although its high cost and limited availability currently restrict widespread use. With further validation and improved cost-effectiveness, it may emerge as a preferred option in the future. The technique described by Pereira-Warr et al[20], involving fascial tightening using two-vector silicone drains, closely resembles our approach and provides a feasible bedside alternative. The authors also recommend an endpoint of approximately 5 cm prior to attempting DFC and obviate the need for additional NPWT by using perforated drains, similar to our use of a fenestrated Bogota bag. Consistent with their findings, we found NPWT to be impractical in our subset of patients with sepsis and bowel oedema.

Table 3 Innovative techniques for dynamic fascial traction for the open abdomen.

Ref.	Study design and population	Technique	Key results	Remarks
Fung et al[6]	Retrospective multicenter case series; 9 patients in critical care units (including sepsis and bowel ischemia); 12 received concomitant NPWT and 8 had Bogota bag coverage	Fasciotens™ device providing vertical sustained traction using a stand with suspended thread retainer; fascial sutures tightened using screw mechanism	Mean OA duration: 3 days; mean initial fascial gap: 15 cm with significant reduction to 10 cm (P = 0.0081); mean time to DFC: 7 days; comparable outcomes in septic and non-septic OA (7.5 days vs 7 days); two long-term incisional hernias; no procedure-related mortality	High cost (approximately ₹3 Lakh per unit); heterogeneous etiologies; limited applicability due to simultaneous use of multiple techniques
Dohmen et al[18]	Retrospective case series; 9 critically ill patients (including sepsis and bowel ischemia)	Fasciotens™ device with vertical sustained traction	Mortality: 3 patients; mean OA procedures: 3 ± 1; mean time to DFC: 9 ± 3 days; 76% reduction in fascia-to-fascia gap; intra-abdominal pressure reduced from 31 ± 8 mmHg to 8.5 ± 2 mmHg; skin irritation and blisters in 3 cases	High cost (~₹3 Lakh per unit)
Mones et al[19]	Retrospective case series; 9 patients (2 vascular, 7 abdominal surgery)	Fasciotens™ device with vertical sustained traction	DFC achieved in 7 of 9 cases; mean OA duration: 9.6 ± 3.8 days; mean initial fascial gap: 14.2 ± 4.0 cm; mean time to DFC after VMMFT: 6.2 ± 3.5 days; no method-related complications	High cost (~₹3 Lakh per unit); heterogeneous patient population
Pereira-Warr et al[20]	Retrospective case series; 8 patients with sepsis, bowel ischemia, or bowel edema	Viscera covered with perforated plastic sheet; suction drain tubing sutured longitudinally to fascia on both sides; additional drain passed circumferentially to provide gradual fascial tightening	Mean OA procedures: 2.4; mean initial fascial gap: 16.8 cm; mean time to DFC: 9.1 days; mean ICU stay: 43.6 days; no 30-day mortality or major complications	Low-cost, bedside, feasible technique; fenestrated drains obviate need for NPWT; DFC feasible when gap is 3-7 cm; stomas do not interfere with closure
Dennis et al[21]	Retrospective case series; 32 patients (predominantly trauma follow-up cases)	Modified Wittmann patch with indigenous transabdominal wall traction device anchored to lateral abdominal wall; medial traction achieved by tightening external bolsters; NPWT used concomitantly	Mean initial fascial gap: 18.5 cm × 30.5 cm; mean OA procedures: 2.2; mean time to DFC: 18.2 days; mean reduction in wound size: 9.8 cm (51.4%); ECF in 4 cases; no incisional hernia or dehiscence; no procedure-related mortality	Cost-effective and indigenous; requires repeated anesthesia and operating-room interventions; intensive training required; DFC endpoint of 2 cm used
Jo Svetanoff et al[22]	Retrospective case series; 3 pediatric patients	Bedside techniques including reinforced silastic silos sutured to fascia with thick polypropylene or polyethylene sutures; DFT achieved using 20-pound weights in two patients; botulinum toxin, horizontal mattress sutures, and NPWT used in one patient	Initial fascial gap: 10-18 cm; OA procedures: 2-3; DFC achieved in 7-10 days in all cases	Bedside tightening feasible due to polyethylene (Ethibond™) sutures; pediatric patients require tailored approaches due to lower abdominal volume and frequent ACS

OA: Open abdomen; DFC: Definitive fascial closure; IAP: Intra-abdominal pressure; NPWT: Negative pressure wound therapy; ICU: Intensive care unit; ACS: Abdominal compartment syndrome; ECF: Enterocutaneous fistula.

Dennis et al[21] described a modified Wittmann patch technique incorporating an indigenous transabdominal wall traction device, which reduces fascial disruption and suture cut-through by distributing tension across the full thickness of the abdominal wall. Jo Svetanoff et al[22] reported the use of silastic silos combined with weighted bedside traction in paediatric patients. Notably, most of these innovative techniques are described in small case series or isolated reports. In contrast, the present study represents a prospective randomized comparison of an indigenous, bedside DFT technique using a simple Bogota bag.

Although a formal cost-effectiveness analysis was not performed, the economic implications of the described technique are noteworthy. The materials used-plastic urine collection bags and standard polypropylene sutures-are universally available and incur negligible cost compared with commercial NPWT-based DFT systems, which may cost several lakhs of rupees per patient. Furthermore, the bedside nature of serial Bogota bag tightening eliminates the need for repeated operating room interventions, anesthesia exposure, specialized equipment, and trained wound-care personnel. The significantly shorter hospital stay observed in the traction group further suggests indirect cost savings. These cumulative factors make this technique particularly attractive in low- and middle-income healthcare settings.

Limitations

This study has several limitations that merit consideration. First, the sample size was relatively small and drawn from a single tertiary-care government hospital, which may limit the generalizability of the findings. Although randomization ensured comparable baseline characteristics between groups, the study population was etiologically heterogeneous, comprising patients with abdominal sepsis, tuberculosis, enteric perforation, and trauma. However, this heterogeneity reflects real-world practice in low-resource settings and was balanced across study arms, thereby minimizing disease-specific confounding.

Second, the primary outcome measure was the time required to achieve a SSD of 5 cm, which serves as a surrogate marker for feasibility of delayed or DFC rather than a direct measure of DFC itself. The study was not powered to evaluate rates of DFC, long-term incisional hernia formation, or quality-of-life outcomes. Similarly, although the technique was inherently low-cost, a formal cost-effectiveness analysis was not performed.

Third, blinding of the operating and postoperative care teams was not feasible due to the nature of the intervention, introducing the potential for performance bias. Finally, longer-term follow-up was incomplete beyond three months in a subset of patients, limiting assessment of late complications such as ventral hernia. Additionally, while the technique is inherently low-cost, a formal health-economic analysis was not performed. Future multicentre studies incorporating standardized long-term follow-up and cost-effectiveness evaluations are required to better define the role of this technique within contemporary OA management algorithms.

Larger multicentre studies with longer follow-up are required to validate these findings and better define the role of this technique within standardized OA management protocols.

CONCLUSION

Serial tightening of a simple Bogota bag provides a feasible, safe, and inexpensive method for achieving DFT in patients with an OA. In this prospective randomized study, the technique was associated with a significantly shorter time to abdominal wall approximation and reduced hospital stay compared with standard non-traction laparostomy management, without an increase in complications or mortality. The method can be performed at the bedside, does not require specialized equipment or negative pressure systems, and is particularly well suited to resource-limited settings with a high burden of abdominal sepsis.

While these findings are encouraging, further multicentre studies with larger sample sizes are needed to assess DFC rates, long-term abdominal wall outcomes, and cost-effectiveness. Nevertheless, serial Bogota bag tightening represents a pragmatic and scalable adjunct in the management of the OA, especially in low- and middle-income healthcare environments.