Background: Optimal management of the open abdomen remains controversial. Study Design: Retrospective review of patients injured during Operations Enduring Freedom and Iraqi Freedom returning to Walter Reed Army Medical Center (WRAMC) from January 2003 to October 2007 for treatment of open abdomen. Results: Three hundred fifty-four patients were evacuated to WRAMC after laparotomy, including 86 patients (24%) with open abdomen. Three transferred patients were excluded. Eighty-three patients, mean age 26 years (range 18 to 54 years), sustaining injury from secondary blast (n = 47), gunshot (n = 29), and blunt trauma (n = 7) were studied. Surgical management included early definitive abdominal closure (EDAC, n = 56; 67%), primary fascial closure (n = 15; 18%), planned ventral hernia (PVH, n = 9; 11%) and vacuum-assisted closure with AlloDerm (n = 3; 4%). EDAC closure involves serial closure with Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh (62%) or AlloDerm (31%). There was no substantial difference in injury mechanism, age, length of evacuation to WRAMC, or Injury Severity Score (average 30) according to closure type. Complications included removal of infected prosthetic mesh in 4 EDAC closure patients (5%). Overall morbidity was lowest (60%) in primary repair patients (p = 0.01). Rates of deep venous thrombosis, pulmonary embolism, abdominal wall hematoma, and infection did not differ between groups. Fistula rate was increased with PVH (20%). Two patients with PVH died. PVH and EDAC mesh complications have been minimized in the last 2 years of the study. Conclusions: Primary closure of fascia is ideal but not always possible. Early definitive closure has avoided PVH. Mesh-related complications have decreased with time.