Because sometimes, the abdomen becomes the enemy.
The Silent Strangler
Abdominal Compartment Syndrome (ACS) is one of trauma’s cruellest tricks.
The bleeding stops. The repairs are done. Numbers look stable.
Then the belly becomes a vice, crushing perfusion, strangling organs, and quietly killing the patient you thought you saved.
ACS isn’t dramatic, it’s progressive.
One hour you’re high-fiving the team.
The next, your ventilator alarms are screaming, the urine bag is empty, and the lactate is doing a moon shot.
Welcome to ACS.
A time-critical catastrophe you must recognise early and fear always.
What Causes the Pressure to Rise?
The trauma abdomen becomes a disaster zone:
- Ongoing bleeding → volume accumulation
- Aggressive resuscitation → bowel oedema + third spacing
- Liver/retroperitoneal swelling
- Tight fascial closure after DCL
- Bowel ischemia → gas + fluid + inflammatory oedema
Pressure rises → perfusion collapses.
The kidneys fail first. The lungs follow.
The heart eventually submits.
In trauma, the abdomen isn’t a container; it’s a compartment with consequences.
Early Alarm Bells, Don’t Ignore These
If any of the following worsen despite resuscitation:
Rising peak inspiratory pressures
Minimal urine output
Tachycardia + hypotension
Increasing lactate + worsening acidosis
Distended tense abdomen
Difficulty ventilating when previously stable
…your brain should already be asking:
“What’s the bladder pressure?”
Because ACS doesn’t ask permission, it takes the kidney first and the brain last.
Bladder Pressure, The Truth Tool
Not optional. Not “maybe later.”
Measure early and serially if suspicion exists.
| Bladder Pressure | Meaning |
| > 12 mmHg | Intra-abdominal Hypertension (IAH) |
| > 20 mmHg + organ dysfunction | ACS — intervene now |
If you’re waiting for the ICU to decide?
You’re waiting too long.
Two Paths to Hell
1.ACS WITH Prior Laparotomy
This one hits you right after you close:
You did your best, haemostasis, repairs, bowel back together, then you closed fascia like a poster child for perfection.
But the bowel was swollen. The liver was angry.
Fluid kept coming.
Pack removal was optimistic.
Nature disagrees.
Result?
Abdominal closure becomes a death sentence.
Management:
- Re-open immediately
- Remove packs if tight
- Inspect for missed bleeding
- Re-pack gently
- Temporary closure (Bogotá bag / VAC / silo)
Rule: Never let aesthetics kill physiology.
When in doubt, leave it open.
2.ACS WITHOUT Prior Laparotomy
Perhaps the most dangerous form.
The abdomen looks untouched.
But inside:
- Z-fluid resuscitation
- Pelvic packing + retroperitoneal hematomas
- Massive liver oedema
- Pancreatic inflammation
- Bowel reperfusion injury
External signs are subtle until a sudden collapse.
Management:
- Sedation + paralysis to reduce abdominal wall tone
- Gentle diuresis if appropriate
- Decompressive laparotomy, before organ failure becomes irreversible
- Temporary closure, no tight fascia
- Continue resuscitation and monitoring
You will be called “too aggressive” until the moment you’re called a hero.
That’s how ACS works.
The Surgeon’s Mistake: Waiting
If you’re talking about whether to open: you should have already opened.
Because every minute of ACS equals:
- Renal ischemia
- Gut ischemia
- Reduced venous return → shock
- Impaired ventilation → hypoxia + hypercarbia
- Reduced cardiac output
- Brain death cloaked in abdominal pressure
Open the abdomen.
Release the devil.
Save the patient.
Closing Later, The Long Road
After decompression:
- Serial exams and pressures
- Optimise perfusion, volume status, infection control
- Gradual closure when physiology + oedema resolve
The timeline is dictated by biology, not your schedule.
Sometimes closure is day 2.
Sometimes day 12.
Sometimes it takes a graft.
You don’t rush perfection in a body that nearly died.
The Philosophy of ACS
Damage control isn’t about technical mastery; it’s about knowing when to stop and knowing when to open again.
The abdomen is both protector and predator.
Respect its pressure.
Measure its pressure.
Respond to its pressure.
And From the Patient’s Side…
They won’t remember the bladder pressures or the decision to cut open a belly that was already sewn shut.
They won’t see the nights you paced, waiting for the lactate to turn.
But their family will remember the moment they woke up, still here, still breathing, still loved.
For us, it’s intra-abdominal hypertension.
For them, it’s the second chance they never saw coming.
