A definitive definition of "hostile abdomen" probably doesn't exist. Nevertheless operations and mainly re-operations in visceral surgery quite often present technical difficulties which are tricky to face even for a skilled and expert surgeon (multiple tenacious adhesions, etc. multiple entero-atmospheric fistulas, etc.). Which are your criteria to foresee a "hostile abdomen" in elective surgery? Which precautions should be taken during surgery and in the post-operative period? What about the "open abdomen procedure?
As a personal opinion - a hostile abdomen is an abdomen that has either undergone previous surgical intervention, has penetrating trauma or sepsis!
Repeated laparotomies drive to a difficult new operation for the future, but the "hostile abdomen" is the one that you are non able to enter. Fistulas are frequently due to the encapsulating peritonitis that you can find frequently, like some abdomen after several years of peritoneal dialysis. If enteric fistulas will appear after the abdomen will be opened and ruled, a laparostomy with or without VAC system for some days/weeks, appears a good option. This is only my opinion.
Personally I define «hostile abdomen» as the abdomen with (1) persistent loss of natural free spaces between intra-abdominal organs and structures of abdominal compartment (anterior abdominal wall, retroperitoneal space, pelvic concavity, etc.), (2) pathological changes of their normal anatomical proportions and (3) syntopy, caused by the massive dense (aggressive) adhesions.
Usually, hostile abdomen is a consequence of previous multiple (>2) laparotomies, secondary peritonitis, severe acute pancreatitis, anastomotic leakage, ostomy, staged management of abdominal trauma, decompressive laparostomy, intestinal Crohn’s disease or extensive radiotherapy.
The main criteria required for the prediction of hostile abdomen include: (1) anamnestic data (previous multiple (>2) laparotomies, secondary peritonitis, severe acute pancreatitis, anastomotic leakage, ostomy, staged management of abdominal trauma, open abdomen techniques, intestinal Crohn’s disease, extensive radiotherapy, peritoneal canceromatosis etc.), (2) clinical data (massive defects or deforming scars of anterior abdominal wall, enterocutaneous or “enteroatmospheric” fistulae, retraction of the abdominal wall edges, persisting bowel obstruction etc.) and (3) data of abdominal visualization (free intra-abdominal space, proportion and syntopy).
From a clinical standpoint hostile abdomen is typical surgical nightmare. This is the case when all the stages of the operation are extremely difficult. In my practice, I use the following simple rules of treatment of patients with hostile abdomen:
1) if there is any alternative to surgery (conservative treatment, puncture, etc..) - do not operate
2) enter the abdomen via a new incision in "virgin" territory or from visualizated free space of abdominal wall
3) the most important surgical tool when entering the abdomen and during adhesiolysis is your fingers
4) perform all stages of the operation under visual and digital control, without hurry, with patience and precision
5) minimize to the rational the basic volume of intervention
6) do not try to radically close up the abdominal wall - when you have doubt - apply the method of open abdomen
I define hostile or catastrophic abdomen as the one where there are firm adhesions in the peritoneal cavity forming a single-block formed basically of bowel and surrounding organs such as liver, pelvic organs and abdominal wall
In my view hostile abdomen can be defined as
If entry is difficult,
Difficult to define normal anatomy apart fromdiseasesd organist
or difficult to take intraoperative decisions about best possible options
Inpostoperative period not settling down even on 5th or 6th post op day
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