Open abdomen closure strategies: a systematic review with stratified meta-analysis of primary fascial closure and narrative synthesis of timing, fistula, and hernia outcomes

Abstract Background Open abdomen (OA) management can be lifesaving, but temporary abdominal closure strategies are heterogeneous and should not be treated as interchangeable. We evaluated closure-facilitating strategies in clinically coherent constructs, using meta-analysis only for comparable primary fascial-closure (PFC) comparisons and narrative synthesis for timing, fistula, and hernia outcomes. Methods We reviewed adult OA studies identified in archived exports from PubMed/MEDLINE, Embase, Scopus, Web of Science Core Collection, and Cochrane CENTRAL. PRISMA 2020 was used as the reporting framework for this manuscript; however, the historical archive did not preserve a complete full-text retrieval/disposition log, reviewer-level evidence of independent duplicate screening, or independent duplicate risk-of-bias forms. The evidence flow was reconstructed from preserved database exports, citation-chain records, and report-level reconciliation, with unavailable process data explicitly reported as not reconstructable. Meta-analysis was restricted to independent two-arm studies with compatible intervention, comparator, PFC estimand, and extractable arm-level data. Random-effects models used REML with Hartung-Knapp adjustment. RoB 2, ROBINS-I, and QUIPS were used according to study design/question, and GRADE was applied to the quantitative PFC evidence. Results The archived database exports contained 2,012 records. After deduplication, 845 unique database-derived records and 9 citation-chain records yielded 854 recoverable historical binary decisions (75 INCLUDE; 779 EXCLUDE). Report-level reconciliation removed 5 prior inclusion entries and identified 18 net additional eligible reports from archived source-export/evidence-map material, producing 88 eligible reports. Mesh-mediated traction plus NPWT was pooled in 2 studies (RR 1.80, 95% CI 1.00–3.26), and non-invasive traction/ABRA plus NPWT in 3 studies (RR 1.74, 95% CI 0.37–8.15; I² = 85.2%). Salamone 2018, Rasilainen 2020, Serclová 2012, and Balhara 2026 were individually audited but were not added to these pools because their estimands, denominators, comparators, extractable data, or cohort independence did not meet the pooling criteria. Fistula, hernia, and timing outcomes were synthesized narratively. Conclusions Comparative data suggest that fascial traction may improve PFC, but the evidence is sparse, heterogeneous, and of very low certainty. No specific device or rigid timing threshold is supported by sufficiently certain evidence, and timing, fistula, and hernia findings remain narrative. The reconstructed nature of the historical screening and risk-of-bias archive, including unrecoverable full-text denominators and incomplete report-level search provenance for the 18 additional reports, further limits reproducibility and requires cautious interpretation. Registration: PROSPERO CRD420261286875.