Serial Bogota bag tightening: A pragmatic advance in open abdomen management for resource-limited settings

Abstract

Open abdomen management poses unique challenges in resource-limited settings, where costly dynamic fascial traction techniques remain inaccessible. Balhara et al's prospective randomized trial published on the World J Gastrointest Pharmacol Ther introduces serial Bogota bag tightening, a bedside, negligible-cost method using urine bags and sutures, as an effective dynamic fascial traction alternative, achieving skin-to-skin distance ≤ 5 cm in 9.94 days vs 13 days in controls (P = 0.0003) and shortening hospital stays without added morbidity. This editorial appraises the study’s strengths, contextualizes it against negative pressure wound therapy/mesh systems, and advocates its scalability for low- and middle-income countries, urging multicenter validation of long-term fascial closure.

Key Words: Open abdomen; Dynamic fascial traction; Bogota bag; Serial tightening; Temporary abdominal closure; Emergency laparotomy; Abdominal sepsis; Resource-limited settings

Core Tip: Balhara et al pioneer randomized, low-cost dynamic fascial traction via serial Bogota bag tightening, accelerating skin-to-skin closure (9.94 days vs 13 days) and hospital stays in septic open abdomen, bedside feasible, universally accessible, and ideal for low- and middle-income countries overburdened by sepsis, bridging the gap until advanced therapies proliferate.

This editorial refers to “Low-cost dynamic fascial traction using serial Bogota bag tightening in open abdomen management: A prospective randomized study” by Balhara K et al, 2026; https://dx.doi.org/10.4292/wjgpt.v17.i2.118848.

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INTRODUCTION

This editorial provides a critical appraisal of Balhara et al’s prospective randomized controlled trials (RCT)[1] (n = 36) validating serial Bogota bag tightening as low-cost dynamic fascial traction (DFT) for open abdomen (OA) management in low- and middle-income countries (LMICs). It contextualizes study strengths/Limitations against negative pressure wound therapy (NPWT)/vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) benchmarks, advocates World Surgical Infection Society (WSIS) tier 3 adoption pending multicenter validation, and addresses global surgery inequities. OA remains a cornerstone of damage control surgery in sepsis and trauma, yet temporary abdominal closure (TAC) techniques falter in LMICs where costly commercial systems like ABThera^TM or Fasciotens^® remain inaccessible[1-5].

Balhara et al’s single-center RCT[1] (n = 36) demonstrated serial tightening of improvised urine bag flaps achieved skin-to-skin distance (SSD) ≤ 5 cm in 9.94 ± 1.88 days vs 13 ± 2.87 days with standard Bogota bags (P = 0.0003), shortening hospital stays (17 days vs 20 days, P = 0.0013) without increased morbidity. This bedside technique, requiring only polypropylene sutures and weekly nurse-led adjustments, offers a pragmatic solution for LMIC sepsis burdens [tuberculosis (TB) peritonitis, enteric perforations] where NPWT costs exceed 300 dollars per dressing and supply chains fail. Figures 1 and 2 show the serial Bogota bag technique, including stepwise tightening, flap suturing, and central traction, as well as the limitations in managing massive abdominal defects in resource-limited settings.

Figure 1 Serial Bogota bag tightening - step-wise application. SSD: Skin-to-skin distance.

Figure 2  Massive open abdomen post-necrosectomy - technique limits.

CLINICAL CONTEXT AND COMPARISONS

Serial Bogota bag tightening represents an innovative evolution from static TAC techniques, achieving SSD ≤ 5 cm, a validated surrogate for fascial approximation, in 9.94 days vs 13 days with standard Bogota bags[6-8]. While SSD ≤ 5 cm correlates strongly with definitive fascial closure rates (70%-80% in VAWCM trials)[9], it remains a proxy endpoint; Balhara et al’s 100% SSD achievement[1] (vs 0% in controls) demonstrates feasibility but requires long-term validation of actual closure and hernia prevention (Table 1)[6,9-18].

Table 1 Comparison of temporary abdominal closure techniques.

Technique	Cost	Bedside feasible	Time to SSD ≤ 5 cm	Fascial closure rate	Key limitations
Standard Bogota bag[10]	Low (1-2 dollars)	Yes	13 days	35%-45%	No traction; domain loss
Serial bag tightening	Negligible (approximately 0.50 dollar)	Yes	9.94 days	SSD ≤ 5 cm (definitive pending)	Surrogate endpoint
Towel clips[11]	Negligible	Yes	14-21 days	20%-30%	Skin necrosis. Poor traction
Wittmann patch alternatives[12]	Moderate (10-20 dollars)	Partial	10-15 days	50%-60%	Reusability issues, infection
Mosquito net mesh traction	Very low (approximately 1 dollar)	Partial	11-14 days	60%-70%	OR-dependent, availability
ABTheraTM NPWT	High (300+ dollars/dressing)	No	10-14 days	70%-80%	Cost, OR-dependent
Fasciotens®[6,13]	High (approximately three hundred thousand rupees)	Partial	7-9 days	70%-80%	Availability
NPWT + mesh (VAWCM)[9,14-17]	High	No	10-14 days	70%-80%	ECF risk; OR-dependent
Perforated drains[18]	Low	Yes	9.1 days	Not reported	Small series

OR: Operating room; NPWT: Negative pressure wound therapy; VAWCM: Vacuum-assisted wound closure and mesh-mediated fascial traction; ECF: Enterocutaneous fistula; SSD: Skin-to-skin distance.

Serial Bogota tightening demonstrates superior speed (9.94 days) and cost-effectiveness vs other low-cost improvised techniques while avoiding towel clip skin necrosis and mesh/operating room dependency, ideal for septic OA in resource-limited settings[18]. Key positioning: This expanded comparison establishes serial Bogota tightening as the optimal low-cost DFT solution: Faster than towel clips/mosquito net (9.94 days vs 11-21 days), cheaper than Wittmann alternatives (approximately 0.50 dollar vs 10-20 dollars), and fully bedside-feasible without skin necrosis risks.

SURROGATE ENDPOINT DISCUSSION

Surrogate endpoint caveat

SSD ≤ 5 cm strongly correlates with definitive fascial closure (70%-80% in VAWCM meta-analyses) but 20%-30% of SSD successes fail actual closure. Balhara et al’s 100% SSD achievement[1] (vs 0% controls) demonstrates feasibility only, definitive closure, hernia prevention, and quality-of-life remain unproven.

Critical limitations of surrogate reliance

SSD is not definitive closure. VAWCM trials show 20%-30% fail fascial closure despite SSD success[19]. Long-term unknowns: Hernia incidence (25%-66% historical OA rates), quality of life unassessed. Single-center: n = 36 limits generalizability beyond TB/enteric fever cohort. Validation hierarchy required: Phase II: SSD → fascial closure correlation (target > 70%); phase III: Multicenter RCTs with definitive closure as primary endpoint; phase IV: 5-year hernia/quality of life surveillance. This positions serial Bogota tightening as promising (level 2b) pending level 1b confirmation of translation from surrogate to clinical outcomes, essential before supplanting proven NPWT benchmarks.

Implications for LMIC practice

Serial Bogota tightening addresses global sepsis burdens mirroring Ethiopia (TB peritonitis, typhoid) and India (enteric fever perforations), where 70% of OA cases occur in resource-limited public hospitals. This frugal innovation transforms urine bags (approximately 0.50 dollar) into DFT, circumventing NPWT barriers (cost > 300 dollars/dressing, supply chain failures, OR dependency).

Bedside feasibility and implementation

Performed weekly at bedside by nurses or junior surgeons using readily available urine collection bags (approximately 0.50 dollar) and polypropylene sutures, it bypasses NPWT barriers including recurrent costs (300+ dollars per dressing), fragile supply chains, and operating theater access[20]. Shortened approximation time (9.94 days vs 13 days) and hospital stays (17 days vs 20 days) generate indirect savings of 300-600 dollars per case in public systems, leveraging fascia’s viscoelastic properties for progressive closure[21].

Training and reproducibility

Requires only basic suture skills acquirable in 1-2 supervised sessions, making it reproducible across healthcare systems, from urban referral centers to rural district hospitals lacking NPWT or Fasciotens^®[22]. Validation in Balhara et al’s septic cohort[1] (n = 36) mirrors LMIC realities, though scale-up needs protocol standardization and competency checklists.

Challenges and mitigation

Potential hurdles include supply variability (mitigated by universal urine bag availability), patient discomfort during tightening (managed via analgesia), and applicability limits in massive defects with domain loss (e.g., post-necrosectomy, Figure 2).

LITERATURE ENGAGEMENT AND GLOBAL CONTEXTUALIZATION

Literature evolution of Bogota bag techniques

Static to dynamic progression: The Bogota bag, originally described by Borraez in 1984 as a sterile 3 L irrigation bag sutured to fascia, has evolved from passive visceral coverage to active fascial traction systems[23]. Early applications focused on abdominal compartment syndrome prevention, but serial tightening innovations mark a paradigm shift from static coverage (35%-45% fascial closure) to dynamic approximation (70%-80% potential)[10,14]. Balhara et al's prospective RCT[1] represents the first randomized validation of suture-mediated DFT using improvised materials, distinguishing it from prior case series and retrospective cohorts.

Precedents and gaps: Coccolini et al’s International Register of OA (IROA) analysis[24] (n = 570) demonstrated Bogota bags improved trauma outcomes vs skin-only closure (31.8% usage), but lacked dynamic traction. VAMMFT trials report superior closure rates (77.3%) but require costly NPWT systems unavailable in LMICs[14]. Pediatric silo adaptations and perforated drain modifications exist, yet no prior study randomized serial tightening against controls in septic cohorts[18,25].

Global burden and LMIC relevance

Epidemiological context: OA incidence parallels surgical pathology burdens[26]: India’s enteric fever/TB profile mirrors Ethiopia’s abdominal sepsis predominance (typhoid, TB peritonitis), while trauma drives 25%-30% of global damage control surgery[27]. World Society of the Abdominal Compartment Syndrome (WSACS)/WSIS guidelines endorse OA for ACS/sepsis, but LMIC implementation lags due to NPWT costs (approximately three hundred thousand rupees) vs urine bags (< fifty rupees).

Resource-stratified recommendation: WSIS/WSACS guidelines support tiered TAC strategies by resource availability. Serial Bogota tightening (level 2b evidence from Balhara et al’s RCT[1]) is recommended for tier 3 LMICs, pending level 1b multicenter validation; high-resource tier 1 settings prioritize VAWCM/NPWT (Table 2).

Table 2 Temporary abdominal closure strategies by resource tier.

Setting	TAC strategy	Closure rate	Cost	Availability
High-income	ABTheraTM/VAWCM[9,14-17]	70%-80%	High	High
Middle-income	Fasciotens®/mesh[6,13]	65%-75%	Moderate	Low
Low-income	Serial Bogota[1]	SSD ≤ 5 cm: 100%	Negligible	Universal

TAC: Temporary abdominal closure; SSD: Skin-to-skin distance; VAWCM: Vacuum-assisted wound closure and mesh-mediated fascial traction.

Global surgery perspective

Serial Bogota bag tightening exemplifies frugal innovation within World Health Organization (WHO) essential surgery frameworks, transforming urine bags (approximately 0.50 dollar) into DFT, bridging NPWT access gaps affecting 5 billion people lacking timely surgical care. This aligns with Global Surgery 2030 goals by: Retooling waste materials (universal urine bags → DFT system); task-shifting to nurses/junior surgeons (1-2 training sessions); eliminating operating room/supply chain dependency (bedside-weekly protocol). Health economics: 3-day hospital reduction = 300-600 dollars savings per case × 1M annual LMIC OA cases = 500 million dollars potential impact. WSIS 2024 tier 3 endorsement positions this as scalable precedent for pragmatic surgical adaptation across Africa (TB peritonitis), Asia (enteric fever), Latin America (trauma). IROA data confirm sepsis/trauma predominance across continents, positioning this technique as a “frugal innovation” per WHO essential surgery frameworks[24,28].

Comparative global validation needs

Multicenter imperative: Enhanced “multicenter imperative” now prioritizes comprehensive long-term endpoints critical for practice-changing level 1b evidence. Primary endpoints (definitive closure metrics): Ventral hernia incidence: 5-year surveillance (target < 20% vs 35%-66% historical OA rates). Delayed fascial closure rates: > 70% target (VAWCM benchmark). Quality of life: Short-Form 36, hernia-specific disability index (hernia-related quality-of-life survey). Abdominal wall reconstruction needs: Component separation, biologic mesh requirements. Secondary endpoints: Cost-effectiveness: 300-600 dollars hospital savings validation across LMIC tiers. Sepsis-specific efficacy: 30-day mortality, enterocutaneous fistula rates. Training reproducibility: District hospital success rates (> 90% competency). Global trial design: Phase III multicenter RCTs spanning LMIC etiologies (Africa: TB/perforations; Latin America: Trauma; Asia: Enteric fever) integrating with WSACS COOL trial framework for adequate power (n > 400). Composite primary outcome: Hernia-free closure at 1 year (Figure 3). This addresses single-center limitations (n = 36) while establishing serial Bogota tightening as scalable level 1b evidence for WSACS/WHO essential surgery guidelines[9,24,29].

Figure 3 Proposed multicenter trial schema (CONSORT flow). LMIC: Low- and middle-income country; RCT: Randomized controlled trial.

Policy integration and global surgery perspective

Serial Bogota bag tightening exemplifies frugal innovation within WHO essential surgery frameworks, adapting universally available urine bags (approximately 0.50 dollar) into DFT, bridging NPWT access gaps that affect 5 billion people lacking timely surgical care. Global burden alignment: Africa (Ethiopia): TB peritonitis, typhoid sepsis drive 70% OA cases. Asia (India): Enteric fever perforations mirror Balhara et al’s cohort[1]. Latin America: Trauma accounts for 25%-30% damage control surgery. WHO 2030 alignment: Addresses “essential surgery crisis” by: Retooling existing materials (urine bags → DFT system). Task-shifting to mid-level providers (nurses/junior surgeons). Bedside scalability eliminates operating room/supply chain dependency. Health economics: 3-day hospital reduction translates to 300-600 dollars savings per case × 1 million annual LMIC OA cases = 500 million dollars potential annual impact. WSIS 2024 resource stratification: Tier 1 (high-resource): VAWCM/NPWT; tier 2 (middle-resource): Mosquito net mesh. Tier 3 (low-resource): Serial Bogota tightening (level 2b evidence, pending level 1b).

This positions serial Bogota as WHO-appropriate innovation, transforming waste materials into life-saving DFT while establishing precedent for pragmatic LMIC surgical adaptation[24,27,29]. While safe in Balhara et al’s septic cohort[1] (n = 36), larger trials should monitor these risks in diverse OA etiologies (Table 3).

Table 3 Risk profile comparison.

Risk	Serial Bogota	Towel clips[11]	NPWT[9]
Skin ischemia	None reported	15%-25%	5%-10%
Suture cut-through	None (polypropylene)	N/A	N/A
Patient discomfort	Minimal (analgesia)	Severe	Moderate
Enterocutaneous fistula	Comparable	Higher	Lower

NPWT: Negative pressure wound therapy; N/A: Not applicable.

Potential risks and limitations of repeated tightening

Balhara et al[1] reported no significant skin ischemia, suture cut-through, or patient discomfort with weekly bedside tightening using continuous polypropylene (Prolene^®) sutures. These risks are mitigated by: Material choice: Non-absorbable polypropylene minimizes cut-through (vs nylon). Weekly intervals: Allows tissue adaptation, preventing pressure necrosis. Progressive tension: 1-2 cm weekly advancement respects fascial viscoelastic limits.

OA management progress overview

DFT techniques have revolutionized OA management since the 2010s, achieving primary fascial closure rates of 65%-90% vs 50%-60% with static methods[8,30,31]. Current progress centers on cost-effective adaptations for LMICs, building on Balhara et al’s serial Bogota bag tightening RCT[1] (SSD 9.94 days vs 13 days, P = 0.0003; Table 4).

Table 4 Study outcomes - serial tightening vs control, mean ± SD.

Outcome	Serial tightening (n = 18)	Control (n = 18)	P value
Time to SSD ≤ 5 cm (days)	9.94 ± 1.88	13.0 ± 2.87	0.0003
Hospital stay (days)	17.0 ± 1.85	20.39 ± 3.17	0.0013
Complications	Comparable	Comparable	NS
Mortality	Comparable	Comparable	NS

NS: Not significant; SSD: Skin-to-skin distance.

Current progress

NPWT combined with DFT dominates guidelines, with VAWCM yielding 80% closure rates and low enteroatmospheric fistula incidence (6%). Innovations like Dynatract^® (porcine model: Reduced fascial edge distance, P < 0.05) and vertical traction devices (88% early closure) enhance precision. Bogota bag serial tightening, as in Balhara et al[1], costs < 5 dollars vs 300 dollars NPWT dressings, enabling LMIC scalability.

Key controversies

Fascial retraction prevention vs hernia risk persists: VAWCM achieves 73% closure under tension but incurs 20%-30% incisional hernia rates at 1 year. Device costs limit adoption, Fasciotens^® (50-60 N traction) succeeds in high-resource settings but fails LMIC feasibility. Early traction (day 1-3) vs delayed application debates enteroatmospheric fistula risk (NPWT alone: 15%; DFT: 5%-10%).

Prevailing viewpoints

WSACS endorses DFT + NPWT as level 1a recommendation for peritonitis OA, prioritizing closure over planned hernia. EAST guidelines favor traction systems (relative risk 0.48 for closure, 95% confidence interval: 0.26-0.87). LMIC consensus advocates improvised techniques like Balhara et al’s urine bag method[1] pending multicenter validation.

Critical appraisal

Limitations of Balhara et al’s trial[1] include its small sample size (n = 36), single-center design, use of surrogate primary outcome (SSD ≤ 5 cm rather than definitive fascial closure rates), lack of blinding, and short follow-up period (3 months, capturing no late hernias but precluding long-term assessment). Etiologic heterogeneity (primarily abdominal TB and enteric fever) mirrors real-world OA scenarios in LMICs yet limits subgroup analyses. While CONSORT adherence, baseline comparability (demographics, Sequential Organ Failure Assessment scores, labs), and data transparency enhance credibility, the absence of sample size calculation, allocation concealment details, and intention-to-treat analysis introduces potential bias. No significant differences emerged in complications or mortality, but power constraints hinder detection of subtle morbidity increases from repeated bedside tightening.

Future directions

Larger multicenter RCTs are essential, prioritizing definitive endpoints: Delayed fascial closure rates (target > 70%, per VAWCM benchmarks), incisional hernia incidence (5-20% in IROA registry data across TAC strategies), patient-reported outcomes (e.g., Short-Form 36 for quality of life, hernia-specific disability indices), and need for abdominal wall reconstruction. Trials should span diverse LMIC etiologies (trauma, sepsis, perforations) and resource tiers, incorporating cost-effectiveness analyses (e.g., hospital stay reductions translating to 300-600 dollars savings per case). Integration with WSACS phase III protocols (e.g., COOL trial) could elevate evidence to level 1b. Additional priorities include head-to-head comparisons of low-cost DFT variants (serial Bogota vs perforated drains, mosquito net mesh), training reproducibility assessments for district hospitals, and long-term ventral hernia surveillance (5-year incidence, quality-adjusted life years). These efforts will validate pragmatic innovations while addressing global surgery inequities.

CONCLUSION

Preliminary level 2b evidence from Balhara et al’s single-center RCT[1] (n = 36) suggests serial Bogota bag tightening may accelerate SSD ≤ 5 cm (9.94 days vs 13 days, P = 0.0003) in septic OA without increased complications. This promising bedside technique (approximately 0.50 dollars) requires multicenter RCTs (target n ≥ 400) confirming definitive fascial closure rates (70% benchmark), hernia incidence, and quality-of-life outcomes before broader LMIC implementation.