Over the last 15 years, the contemporary strategies to treat the open abdomen have reduced the lethal complications. Systematic intensive care and modern wound management in conjunction with a plastic barrier to protect the viscera and topical negative pressure on the soft tissues have reduced the development of small bowel fistulas. The literature selected for this review shows that the surgical handling of the exposed bowel, the choice of the material for temporary coverage and early progressive closure of the defect are crucial for the prevention of fistulas. At present, surgeons worldwide have adopted these principles leading to an increase of primary or delayed closure rates. When a small fistula occurs, biological dressings like human acellular dermal matrix and fibrin glue may help to seal the orifice and to treat the patient conservatively. In case of a large fistula, vacuum-assisted wound management is recommended as well. Through a separate hole in the vacuum sponge matching to the fistula, the enteric contents are sucked off while the wound bed heals and is prepared for split thickness skin graft. Surgical resection of established fistula unresponsive to conservative measures should only be performed on patients well-nourished and free of infection with a delay of at least six months. For patients with an open abdomen, surgical expertise and a well-structured management plan offer the best chances to overcome this potentially devastating condition--with or without fistula.