tangential hydrosurgery: a paradigm shift in surgical ... · • describe the concept of wound bed...

Tangential Hydrosurgery: A Paradigm Shift in Surgical Technology

Objectives

• Describe the concept of Wound Bed Preparation

• Develop an understanding of available techniques for achieving appropriately prepared wound bed

• Discuss the technical aspects of hydrodissectionand its clinical application

TIME - The principles of wound bed preparation

Tissue removal of non-viable or deficient tissue

Infection reduce bacterial bioburden

Moisture restore moisture imbalance

Edge edge of wound is non-advancing

“T” Tissue – non-viable or deficient

Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

The first step in Wound Bed Preparation is to remove the necrotic tissue. This process is important for several reasons:

1. Devitalized tissue (eschar and slough) in the wound bed will reduce the ability of the clinician to adequately assess the depth of the wound, condition of the tissue and surrounding structures.

2. It may mask signs of infection and serve as a medium for the proliferation of bacteria.

3. The presence of necrotic tissue is a physical barrier to healing and necrotic tissue supports significant bacterial growth which may result in excessive amounts of proteases which can have a very negative effect on healing.

“I” Infection or inflammation

Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

The presence of a wound creates a portal of entry for bacteria. One of the most significant predisposing factors for a wound infection is inadequate blood supply. For example in pressure ulcers or ischemic leg ulcers.

This pressure ulcer is covered with eschar & has evidence of surrounding cellulitis. A swab culture is insufficient in this case. The eschar is being unroofed & a direct culture is obtaining at that point.

“M” Moisture imbalance

Too wet – macerated edges Proper moisture balance

Courtesy of Dr. Greg Schultz Courtesy of Dr. Greg Schultz

“E” Edge – Non advancing or undermined

Courtesy of Dr. Parham Ganchi Courtesy of Dr. Parham Ganchi Courtesy of Dr. Parham Ganchi

Interventions for a non-advancing wound margin may include debridement, biological agents, skin grafts, and adjunctive therapies. Debridement of necrotic tissue or callus (in the case of neuropathic ulcers) may be helpful for the non-advancing wound edge. Biologic agents include Human Fibroblast-Derived Dermal Substitute and growth factors (applied at the right time).

…the most fundamental technology of Wound Bed Preparation

Surgical wound debridement

Current concept of surgical debridement

“T” Remove necrotic and diseased tissue

“I” Drain infection, remove infected tissue

“M” Excise desiccated tissue

“E” Wound progression post debridement

Courtesy of Dr. Mark Granick

Surgical debridement

When properly performed, surgical wound debridement removes devascularized tissue and necrotic material, eliminates dead space and reduces wound contamination

Classic Principles of Surgical Debridement

•Early, radical excision

•Rapid resuscitation

•Removal of necrotic tissue

•Preservation of viable skin

•Planned incisions to facilitate reconstruction

•Inspect deep fascia and muscle

•Pack wound

•Reoperate if necessary


Hydrosurgical Principles of Surgical Debridement

• Complete removal of undesirable tissue

• Maximum preservation of collateral tissue

• Wound closure

Courtesy of Dr. Jeff Nelson Courtesy of Dr. Jeff Nelson

The Clinical Benefits of Debridement• Removes necrotic tissue that impairs wound healing

• Creates bacterial balance in the wound

• Results in controlled bleeding that stimulates the production of blood-borne growth factors

• Removes the senescent fibroblasts – leaving younger, more viable cells

• Removes the hyperproliferative, non-migratory wound edge that slows healing

Thorough debridement is essential for the wound repair process.

Role of Debridement

•Cleaning the wound

•Removal of foreign material

•Removal of devitalized and severely damaged tissue

•Decrease bacterial counts

•Remove necrosis

•Control infection

•Remove dessicatedtissues

•Conversion to an acute wound

Acute Wounds Chronic Wounds

Surgical debridement literature

• Improves host defense mechanisms and reduces active infection (Elek 1956)

•May enhance chronic wound healing (Steed et al 1996)

•Reduces dysfunctional cell populations (Hasan et al 1997, Vande Berg et al 1998)

•Promotes release of tissue cytokines and growth factors (Enoch & Harding 2003)

Surgical management of an infected wound

• Incision and drainage

• DEBRIDEMENT



Management of necrosis

•DEBRIDEMENT

•Remove foreign bodies

•Remove sequestra

•Remove avascular tissue


Debridement Options•Mechanical

• Autolytic

• Biologic

• Enzymatic

• Surgical–Curette, Scissor, Scalpel

• Hydrosurgery


Classic methods of debridement

•Radical excision is required for complex wounds•Scalpels are non-selective•Limitations exist for pulse lavage•Other invasive modalities cause collateral injury


Tangential Hydrodissection: the new age of debridement

Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

Open wound of armBEFORE –


AFTER SURGERY –Courtesy of Dr. Mark Granick

VERSAJET Debridement –Courtesy of Dr. Mark Granick

During the 45 minute surgery, the only instruments used were the incision and Drainage tray with minimal equipment, dermatome, a mesher and the VERSAJET.

Final Closure with STSG

CLOSED SKIN GRAFT –Courtesy of Dr. Mark Granick

4 DAYS AFTER SURGERY –Courtesy of Dr. Mark Granick

1 MONTH POST OP –Courtesy of Dr. Mark Granick

Hydrosurgical System

• High velocity stream of saline– .005 of an inch in

diameter– The size of a human

hair

• This super sonic stream of saline WILL– Hold tissue– ablate tissue– remove waste

Advantages of tangential hydrodissection in medical applications

– CLEAN, FAST, and PRECISE

– Tangentially removes tissue– Operation is clearly visible– No thermal effects– Time and cost savings– Improves patient outcomes

Hydrosurgery System

Powered Console

Disposable Handpiece

Foot Pedal

Saline

Waste Container

(NO SUCTION)

Versajet® – An Advanced Hydrosurgery Product

Venturi EffectThe design of the VersaJet is such that the high-velocity fluidjet passes across the operating window and into the evacuation collector creating a localized vacuum to hold and cut targeted tissue while aspirating debris from the site.

Tissue ExcisionAdditional design attributes allow the user to finely control excision. Orienting the operating window parallel to the tissue optimizes the VersaJet’s performance for tissue excision – cutting and aspiration.

Contaminant RemovalAlternatively, orienting the operating window obliquely to the tissue optimizes the VersaJet’s performance for contaminant removal – irrigation and vacuuming.

VERSAJET tip configuration

The VersaJet is available in three tip configurations. A 15 degree angle with a 14mm operating window, a 45 degree angle with a 14mm operating window and a 45 degree angle with an 8mm operating window.

Basic Clinical Applications of the HydrosurgicalSystem

Orthopedics– Debridement of open fractures– Osteomyelitis– Soft tissue infections– Joint revisions

Plastic Surgery– Skin graft preparation– Decubitus ulcers– Burns– Exfoliative Disorders– Debridement of acute & chronic

wounds of any type

Courtesy of Dr. Jeff Nelson


Basic Clinical Applications of the HydrosurgicalSystemTrauma & General Surgery– Debridement of traumatic

wounds– Road-rash– De-gloving injuries– Debridement of pressure

ulcers– Contaminated wounds– Debridement of burns



Basic Clinical Applications of the HydrosurgicalSystem

Vascular Surgery– Debridement of vascular

ulcers– Diabetic ulcers

Podiatry– Debridement of diabetic

foot ulcers– Amputations




Granick, 2006 Versajet (n=45)-vs-conventional debridement (n=22)

(in press WRR 2006)

Chronic (mostly pressure ulcer)

Acute (surgical wound complication, trauma)

VJ is more precise -maximal preservation of viable tissue

Fewer debridement procedures required (1.2-vs-1.9)

Clinical Evidence

Granick MS, Posnett JW, Jacoby M, Noruthum S, Ganchi PA, Datiashvilli RO. Efficacy and cost-effectiveness of the high-powered parallel water jet for wound debridement. WRR, 2006, 14, 394-397.

Mosti, 2005Versajet debridement (n=54). Non-comparative (outpatient setting)

(Used obliquely at a low setting for gentle mechanical debridement)

Lower limb ulcers (mostly chronic) -venous(14), arterial(16), mixed(1), vasculitis(16), trauma (1)

VJ is selective. Most achieved good debridement with a single procedure. Pain well tolerated

Can be used in OP-could reduce LOS and promote quicker healing

Clinical Evidence

Mosti G, Iabichella ML. Picerni P, Magliaro A, Mattaliano V. The debridement of hard to heal leg ulcers by means of a new device based on fluidjet technology. International Wound Journal, 2005, 2; 307-314

Klein, J Burn Care Rehabil, 2005VJ debridement of burn wounds (n=44). Non-comparative.

Burn wounds. Removal of eschar to eye lids, fingers, web spaces

More effective debridement in difficult areas (cfGoulian and Watson knives)

No patient required re-excision. No graft loss

Clinical Evidence

Klein MB, Hunter S, Heimbach DM, et al. The Versajet water dissector: a new tool for tangential excision. J Burn Care Rehabil. 2005;26(6):483–487.

Rennekampff, Burns, 2006.

VJ debridement of burn wounds (n=17). Non comparative.

Debridement of superficial, mid-dermal and deep partial thickness burns, suitable for Biobrane or autografting.

Can successfully ablate burned necrotic tissue in vivo.

No adverse effects were identified

Preliminary evidence that debridement with VJ may reduce bacterial load on burn wounds

Clinical Evidence

Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32(1):64–69.

Economic data

• Retrospective review of patients with excisionaldebridement of wound (ICD-9-CM Code 86.22) using Versajet – 40 patients with 45 wounds

• Control sample of patients with similar wound types, whose wound was debrided by conventional means– 22 patients with 22 wounds

• Information was extracted from medical notes and billing records

•University Hospital (Newark, NJ) 2003

Clinical and Economic Impact of HydrosurgicalDebridement on Chronic Wounds

Wounds - ISSN: 1044-7946 - Volume 18 -Issue 2 - February 2006 - Pages: 35 - 39

Mark S. Granick, MD; Michael Jacoby; Shyam Noruthrun, APN; Ramazi O. Datiashvili, MD; Parham A. Ganchi, MD

Clinical and Economic Impact of HydrosurgicalDebridement on Chronic Wounds

Wounds - ISSN: 1044-7946 - Volume 18 - Issue 2 -February 2006 - Pages: 35 - 39

Mark S. Granick, MD; Michael Jacoby; Shyam Noruthrun, APN; Ramazi O. Datiashvili, MD; Parham A. Ganchi, MD

The mean cost of a surgical debridement at University Hospital was $3,393. On this basis, the expected cost of debridement was $6,700 per patient with conventional techniques (mean of 2 procedures per patient) compared with $3,900 with the waterjet (mean of 1.14 procedures).No health and safety issues (eg, sharps injuries, splash-back contamination) were reported with the use of the waterjet during the study period.

Economic Data: Results

• Financial Impact in this study– Fewer procedures – Improved outcomes– Decreased costs

◦ Cost per procedure $ 3,393.◦ Cost savings per patient when using Versajet:

$2,800.

•University Hospital (Newark, NJ) 2003

Case Study: Chronic Wound

Courtesy of Dr. Joseph V. Boykin, Jr.Courtesy of Dr. Joseph V. Boykin, Jr.


Courtesy of Dr. Joseph V. Boykin, Jr. Courtesy of Dr. Joseph V. Boykin, Jr.

Debridement procedure with VERSAJET a case of limb salvage. This patient is a diabetic with an advanced mixed infection in a neuropathic lower extremity. He also has osteomyelitis of the calcaneous.


Courtesy of Dr. Joseph V. Boykin, JrCourtesy of Dr. Joseph V. Boykin, Jr

As you can see here we have been able to effectively remove the non-viable tissue while sparing the healthy tissue and not significantly enlarging the area of damage.

Case Study: Acute Wound Crush injury

Courtesy of R. Datiashivili, MD Courtesy of R. Datiashivili, MD

Courtesy of R. Datiashivili, MD

Photo Left: Crush injury to the ankle and foot. The injury consists of devitalized and crushed skin and soft tissues.

Photo Middle: Following serial VERSAJET debridements, the wound bed preparation was adequate to support a skin graft.

Photo Right: Meshed split thickness skin graft applied to the prepared wound bed resulted in successful closure of the wound.

Case Study: Acute Wound Road dirt




Case Study: Acute Wound Open fracture

Courtesy of P. Ganci, MD, PhD

Photo Left: Left leg wound at the time of initial surgery. Note the extensive contamination of the wound with road dirt.

Photo Top Right: After several VERSAJET debridements with intervening negative pressure therapy, the left leg wound bed was significantly prepared.

Photo Bottom Right: Closure of the left leg wound with a latissimus free flap and skin graft.



Case Study: Acute Wound Traumatic hand amputation

Courtesy of R. Datiashvili, MD Courtesy of R. Datiashvili, MD

Courtesy of R. Datiashvili, MD

Courtesy of R. Datiashvili, MD

Case Study: Infected Wound

Courtesy of Dr. Richard Gamelli



This patient had a streptococcal invasive infection and was profoundly hypotensive and acidotic .Following debridement with Versajet she was out of the operating room and completely excised and debrided in one sitting.

Case Study: Infected Wound

Courtesy of Dr. Richard GamelliCourtesy of Dr. Richard Gamelli


Case Study: Friction Burn

Courtesy of P. Ganchi, MD, PhD

Courtesy of P. Ganchi, MD, PhD

Courtesy of P. Ganchi. MD. PhD

Through the use of the VERSAJET, a healthy wound bed was obtained with minimal injury to collateral tissue and complete removal of road dirt. Sharp tangential excision is difficult toperform with accuracy over curved surfaces such as the breast. The debridement had to remove road dirt as well as remain superficial enough to preserve the areolar pigment. The additional of advanced therapies, such as negative pressure therapy and acellular dermal matrix, facilitated a rapid and successful recovery with minimal scar deformity.

Summary

• In the scheme of the “TIME” sequence, waterjetdebridement quickly moves the wound through all phases of wound bed preparation

• Paradigm shift in surgical management

International Advisory Board on Surgical Wound ManagementSetting the standard of care in surgical debridement

• Christopher Attinger• Joseph Boykin• Mellick Chehade• John Davidson• Richard Gamelli• Mark Granick• Steven Jeffery• Charles Lee• Michele Pascone• Roy Kimble

• James Mahoney

• Giovanni Mosti

• Thomas Nolte

• Oliver Rennekampff

• Mayer Tenenhaus

• Lawrence Webb

• Scott Levin

• Luc Teot

• Michael Suk

• Peter Giannoudis

International Advisory Board on Surgical Wound ManagementSecond Annual Meeting, Cascais, Portugal, March 2006

References• Falanga V. Wound bed preparation and the role of enzymes: a case for multiple actions of therapeutic agents.

Wounds 2002; 14: 47–56.

• Yager DR, Zhang LY, Liang HX, Diegelmann RF, CohenIK. Wound fluids from human pressure ulcers contain elevated matrix metalloproteinase levels and activity compared to surgical wound fluids. J Invest Dermatol 1996; 107:743–8.

• Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C,Harding K, Romanelli M, Stacey MC, Teot L, VanscheidtW. Wound bed preparation: a systematic approach to wound management. Wound Rep Reg 2003; 11: S18.

• Schultz GS, Mozingo D, Romanelli M, Claxton K. Wound healing and TIME. New concepts and scientific applications. Wound Repair Reg 2005; 13: S1–S11.

• Granick M, Boykin, J, Gamelli, R, Schultz, G, Tenenhaus, M, Toward a common language: surgical wound bed preparation and debridement. Wound Rep Reg 2006; 13 S1 – S10.

• Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the Wound Bed -Debridement, Bacterial Balance and Moisture Balance. Ostomy Wound Management. 46(11)14-35, 2000.

• Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration.8:347-352, 2000.

References

• Robson M, Heggers J. Delayed wound closures based on bacterial counts. J Surg Oncol 1970; 2: 379–83.

• Robson, MC. Wound Infection: A Failure of Wound Healing Caused by an Imbalance of Bacteria. Surgical Clinics of North America 1997;77(3)637-651.

• Enoch S, Harding K. (2003). Wound bed preparation: the science behind the removal of barriers to healing. Wounds, 15(7): 213-229.

• Steed DL, Donohoe D, Webster MW, Lindsley l, and the Diabetic Ulcer study Group. Effect of Extensive Debridement and Treatment on the Healing Diabetic Foot Ulcer. Journal of the American College of Surgeons 1996;183:61-64

• Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration 2000;8:347-352.

• Sibbald RG, Schultz GS, Coutts P, Orsted H, Keast D. Preparing the wound bed 2003: focus on infection and inflammation. Ost Wound Mgt 2003; 49: 24–51.

• Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections:risk factors for mortality and strategies for management.Ann Surg 1996; 224: 672–83.

• Granick M, Posnett J, Jacoby M, Noruthum S, Ganchi P, Datiashvili R. Efficacy and cost-effectiveness of the highpowered parallel waterjet for wound debridement. Wound Rep Reg 2006, 14, 394-397.

References

• Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32(1):64–69.

• Klein MB, Hunter S, Heimbach DM, et al. The Versajet water dissector: a new tool for tangential excision. J Burn Care Rehabil. 2005;26(6):483–487.

• Draegar RW, Dahners, LE. Traumatic wound debridement. J Orthop Trauma 2006; (20) 2, 83-88.

• Hassinger, SM, Harding, G, Wongworawat, MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clinical Orthopaedics and Related Research, Number 439, 27-31.

• Boyd JI, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clinical Orthopaedics and Related Research, Number 427, 13-17.

• Marakis LL, Cosgrove SE, et al. An outbreak of multi-resistant acinetobacter baumannii associated with pulsatilelavage wound treatment. The Journal of the American Medical Association, 2004 December 22/29.

• Granick MS, Jacoby, M, et al. Clinical and economic impact of hydrosurgicaldebridement on chronic wounds. WOUNDS: A Compendium of Clinical research and Practice, 2006 (18), 2 February, 35-39. Granick MS,

References

• Datiashvili RO, Ganchi PA, et al. Medical application of the high powered parallel waterjet. WaterJet Technology Association Jet News, 2005 December. www.wjta.org .

• Elek S. Experimental staphylococcal infections in the skin of man. Ann NY Acad Sci 1956; 65: 85–90.

• Hasan A, Murata H, Falabella A, Ochoa S, Zhou L, Badiavas E, Falanga V. Dermal fibroblasts from venous ulcers are unresponsive to the action of transforming growth factor-b 1. J Dermatol Sci 1997; 16: 59–66.

• Vande Berg JS, Rudolph R, Hollan C, Haywood-Reid PL .Fibroblast senescence in pressure ulcers. Wound Rep Reg1998; 6: 38–49.

• Mosti G, Iabichella ML. Picerni P, Magliaro A, Mattaliano V. The debridement of hard to heal leg ulcers by means of a new device based on fluidjet technology. International Wound Journal, 2005, 2; 307-314

http://www.wjta.org/

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