Tangential Hydrosurgery: A Paradigm Shift in Surgical Technology

Transcription

1 Tangential Hydrosurgery: A Paradigm Shift in Surgical Technology

2 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 hydrodissection and its clinical application

3 TIME - The principles of wound bed preparation Tissue Infection removal of non-viable or deficient tissue reduce bacterial bioburden Moisture restore moisture imbalance Edge edge of wound is non-advancing

4 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.

5 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.

6 M Moisture imbalance Courtesy of Dr. Greg Schultz Too wet macerated edges Courtesy of Dr. Greg Schultz Proper moisture balance

7 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).

8 Surgical wound debridement the most fundamental technology of Wound Bed Preparation

9 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

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

11 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 Courtesy of Dr. Mark Granick

12 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

13 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.

14 Role of Debridement Acute Wounds Cleaning the wound Removal of foreign material Removal of devitalized and severely damaged tissue Decrease bacterial counts Chronic Wounds Remove necrosis Control infection Remove dessicated tissues Conversion to an acute wound

15 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)

16 Surgical management of an infected wound Incision and drainage DEBRIDEMENT Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

17 Management of necrosis DEBRIDEMENT Remove foreign bodies Remove sequestra Remove avascular tissue Courtesy of Dr. Mark Granick

18 Debridement Options Mechanical Autolytic Biologic Enzymatic Surgical Curette, Scissor, Scalpel Hydrosurgery Courtesy of Dr. Mark Granick

19 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 Courtesy of Dr. Mark Granick

20 Tangential Hydrodissection: the new age of debridement Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

21 Open wound of arm VERSAJET Debridement Courtesy of Dr. Mark Granick BEFORE Courtesy of Dr. Mark Granick AFTER SURGERY 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.

22 Final Closure with STSG 4 DAYS AFTER SURGERY Courtesy of Dr. Mark Granick 1 MONTH POST OP Courtesy of Dr. Mark Granick CLOSED SKIN GRAFT Courtesy of Dr. Mark Granick

23 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

24 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

25 Hydrosurgery System Saline Powered Console Disposable Handpiece Foot Pedal Waste Container (NO SUCTION)

26 Versajet An Advanced Hydrosurgery Product Venturi Effect The design of the VersaJet is such that the highvelocity 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 Excision Additional 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 Removal Alternatively, orienting the operating window obliquely to the tissue optimizes the VersaJet s performance for contaminant removal irrigation and vacuuming.

27 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.

28 Basic Clinical Applications of the Hydrosurgical System Orthopedics Debridement of open fractures Osteomyelitis Soft tissue infections Joint revisions Courtesy of Dr. Jeff Nelson Plastic Surgery Skin graft preparation Decubitus ulcers Burns Exfoliative Disorders Debridement of acute & chronic wounds of any type Courtesy of Dr. Jeff Nelson

29 Basic Clinical Applications of the Hydrosurgical System Trauma & General Surgery Debridement of traumatic wounds Road-rash De-gloving injuries Debridement of pressure ulcers Contaminated wounds Debridement of burns Courtesy of Dr. Jeff Nelson Courtesy of Dr. Jeff Nelson

30 Basic Clinical Applications of the Hydrosurgical System Vascular Surgery Debridement of vascular ulcers Diabetic ulcers Courtesy of Dr. Jeff Nelson Podiatry Debridement of diabetic foot ulcers Amputations Courtesy of Dr. Jeff Nelson Courtesy of Dr. Jeff Nelson

31 Clinical Evidence Granick, 2006 Versajet (n=45)-vsconventional 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) 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,

32 Clinical Evidence Mosti, 2005 Versajet 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 OPcould reduce LOS and promote quicker healing 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;

33 Clinical Evidence Klein, J Burn Care Rehabil, 2005 VJ 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 (cf Goulian and Watson knives) No patient required re-excision. No graft loss 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):

34 Clinical Evidence Rennekampff, Burns, VJ debridement of burn wounds (n=17). Non comparative. Debridement of superficial, middermal 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 Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32(1):64 69.

35 Economic data Retrospective review of patients with excisional debridement 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

36 Clinical and Economic Impact of Hydrosurgical Debridement on Chronic Wounds Mark S. Granick, MD; Michael Jacoby; Shyam Noruthrun, APN; Ramazi O. Datiashvili, MD; Parham A. Ganchi, MD Wounds - ISSN: Volume 18 - Issue 2 - February Pages: 35-39

37 Clinical and Economic Impact of Hydrosurgical Debridement on Chronic Wounds Mark S. Granick, MD; Michael Jacoby; Shyam Noruthrun, APN; Ramazi O. Datiashvili, MD; Parham A. Ganchi, MD Wounds - ISSN: Volume 18 - Issue 2 - February Pages: 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.

38 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

39 Case Study: Chronic Wound Courtesy of Dr. Joseph V. Boykin, Jr. Courtesy of Dr. Joseph V. Boykin, Jr.

40 Case Study: Chronic Wound 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.

41 Case Study: Chronic Wound Courtesy of Dr. Joseph V. Boykin, Jr Courtesy 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.

42 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.

43 Case Study: Acute Wound Road dirt Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick Courtesy of Dr. Mark Granick

44 Case Study: Acute Wound Open fracture Courtesy of P. Ganci, MD, PhD 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. Courtesy of P. Ganci, MD, PhD

45 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

46 Case Study: Infected Wound Courtesy of Dr. Richard Gamelli Courtesy of Dr. Richard Gamelli 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.

47 Case Study: Infected Wound Courtesy of Dr. Richard Gamelli Courtesy of Dr. Richard Gamelli Courtesy of Dr. Richard Gamelli

48 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 to perform 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.

49 Summary In the scheme of the TIME sequence, waterjet debridement quickly moves the wound through all phases of wound bed preparation Paradigm shift in surgical management

50 International Advisory Board on Surgical Wound Management Setting 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

51 International Advisory Board on Surgical Wound Management Second Annual Meeting, Cascais, Portugal, March 2006

52 References Falanga V. Wound bed preparation and the role of enzymes: a case for multiple actions of therapeutic agents. Wounds 2002; 14: 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: 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, Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration.8: , 2000.

53 References Robson M, Heggers J. Delayed wound closures based on bacterial counts. J Surg Oncol 1970; 2: Robson, MC. Wound Infection: A Failure of Wound Healing Caused by an Imbalance of Bacteria. Surgical Clinics of North America 1997;77(3) Enoch S, Harding K. (2003). Wound bed preparation: the science behind the removal of barriers to healing. Wounds, 15(7): 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: 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: Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections:risk factors for mortality and strategies for management.ann Surg 1996; 224: 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,

54 References Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32(1): 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): Draegar RW, Dahners, LE. Traumatic wound debridement. J Orthop Trauma 2006; (20) 2, Hassinger, SM, Harding, G, Wongworawat, MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clinical Orthopaedics and Related Research, Number 439, Boyd JI, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clinical Orthopaedics and Related Research, Number 427, Marakis LL, Cosgrove SE, et al. An outbreak of multi-resistant acinetobacter baumannii associated with pulsatile lavage 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, Granick MS,

55 References Datiashvili RO, Ganchi PA, et al. Medical application of the high powered parallel waterjet. WaterJet Technology Association Jet News, 2005 December. Elek S. Experimental staphylococcal infections in the skin of man. Ann NY Acad Sci 1956; 65: 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: Vande Berg JS, Rudolph R, Hollan C, Haywood-Reid PL.Fibroblast senescence in pressure ulcers. Wound Rep Reg1998; 6: 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;