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

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.

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.

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.