What Data Are There to Support the Use of Hydrosurgery in Wound Debridement Procedures?

Summary

• The VERSAJET◊ Hydrosurgery System is intended for wound debridement (acute and chronic wounds, burns), soft tissue debridement and cleansing of the surgical site in applications that, in the physician’s judgment, require sharp debridement.
• Data from multiple studies support the capacity of hydrosurgery to deliver positive clinical outcomes, including precise and controlled tissue removal, acceptable pain levels, low levels of intraoperative blood loss and volumes of blood transfusion, and effective wound bed preparation for skin grafts and biological dressings.^1–20 Debridement using hydrosurgery has also been shown to lead to a reduction in bacterial load compared with pre-debridement levels^{4,10,13,21,22} and a reduction in healing time compared with other debridement methods.^23,24
• Furthermore, hydrosurgery has been shown to deliver favorable health economic outcomes compared with other debridement methods, including fewer procedures to achieve wound closure and healing, use of fewer instruments, and shorter operating room time.^{4,7,9,10,24–28}

Clinical Outcomes

Controlled tissue removal and preservation of viable tissue

The VERSAJET System achieves controlled tissue removal and helps to preserve viable tissue.^{2,3,6,8,12,14–17}

The VERSAJET System has been shown to provide controlled debridement and facilitate precise excision of necrotic tissue and other unwanted material from the wound surface, whilst preserving viable tissue.^6,12 Three studies have demonstrated the successful use of the VERSAJET System for the debridement of burns, due to the ability to remove non-vital tissue and debris whilst preserving the dermis.^3,6,14 These include a prospective randomized controlled trial, in which significantly more viable tissue was lost from burn wounds in pediatric patients who underwent conventional debridement than those who underwent debridement using the VERSAJET System (p=0.02; Figure 1).⁶

The VERSAJET System has also been shown to precisely and safely debride superficial and intermediate-depth burned necrotic tissue,¹⁵ and, in pediatric burn patients, to preserve viable dermis at low settings (Figure 2).^3,6,14 Moreover, it enables controlled tissue removal particularly evident on contoured areas such as the face, feet, hands and web spaces, and genitals in pediatric and adult patients.^2,8,15–17

In a multicenter prospective case series of patients with mixed wound types, 44/47 patients (94%) achieved adequate debridement after a single procedure with the VERSAJET◊ System. Additionally, 43/47 wounds (91%) did not progress into deeper tissues layers during hydrosurgery, indicating a high degree of tissue preservation (Figure 3).¹²

Pain

Debridement using the VERSAJET System has been shown to be tolerable, with acceptable pain levels reported by patients.^5,13

Studies in patients with chronic wounds and leg ulcers have reported that the pain associated with the VERSAJET System was generally mild to moderate and acceptable for the majority of patients.^_5,13 This is in part due to the ability to adjust the power settings (pressure and velocity of the saline jet) according to the tolerance of the patient and perform successful debridement at low settings, avoiding the need for anesthesia in some patients.^5,13

A comparative study in chronic leg ulcer patients found that those undergoing debridement using the VERSAJET System, who did not receive general anesthesia, reported lower mean visual analog scale (VAS) pain scores compared with the patients treated with moist dressings (Figure 4).¹³

Bleeding

Debridement using the VERSAJET System has demonstrated lower intraoperative blood loss and blood transfusion volumes compared with conventional debridement.^1,9,10,20

In a prospective randomized study assessing the treatment of delayed healing wounds, debridement with the VERSAJET System resulted in less intraoperative blood loss in the first excision procedure and significantly less maximum blood loss for overall excision procedures (p=0.003), compared with conventional debridement.¹⁰ The proportion of patients who experienced ‘severe’ or ‘moderate’ blood loss was smaller in the VERSAJET System debridement group than the conventional debridement group (Figure 5).¹⁰

Two retrospective studies in patients with burn wounds demonstrated that debridement with the VERSAJET System was associated with a significantly lower mean volume of blood transfusion (p=0.036) and mean intraoperative blood loss per unit area of grafted skin (p=0.048), respectively, compared with conventional debridement (Figure 5).^1,9

Bacterial burden

The VERSAJET◊ System has been shown to successfully debride acute and chronic wounds, leading to a reduction in the bacterial load in the treated areas, compared with baseline levels.^{4,10,13,21,22}

In two case series, the VERSAJET System has been shown to effectively remove large amounts of embedded contaminants, such as foreign materials from blast injuries and mineral pitch from road surfaces, which could act as a source for infection.^2,16 Several studies have demonstrated that debridement of acute and chronic wounds using the VERSAJET System led to a reduction in bacterial load, compared with baseline levels (Figure 6).^10,13,21,22 The use of hydrosurgical debridement in full-thickness wounds in pigs also resulted in a significant reduction in total bacterial count and inflammatory neutrophil markers, compared with pre-debridement levels (p=0.031; Figure 6).²⁹ This study also demonstrated that the VERSAJET System was able to remove biofilm bacteria embedded in the granulation tissue, which can delay healing and resist antimicrobial therapies.²⁹

There is evidence to suggest that debridement using the VERSAJET System in a variety of wound types provides comparable levels of bacterial load reduction to other debridement methods, including pulse lavage and conventional surgical/sharp debridement (Figure 7).^10,21,22

Wound bed preparation

The VERSAJET◊ System has been shown to effectively debride and prepare wound beds for the successful application of biological dressings and skin grafts.^{3-7,11–14,16,18,19}

The VERSAJET System has been shown to adequately debride the wound beds of acute and chronic wounds, including diabetic foot ulcers (DFUs), venous leg ulcers, pressure injuries (PIs), and burns, often in just one procedure.^5,12,13

In a multicenter study of 47 patients with mixed wound types, debridement with a single procedure using the VERSAJET System was deemed adequate in 94% of patients (Figure 3).¹² In a study of 142 patients with chronic leg ulcers and a case series of 39 patients with 53 chronic wounds, successful debridement using the VERSAJET System was achieved in the majority patients in a single procedure (Figure 8).^5,13 In the 39-patient case series, all chronic wounds were improved post-debridement, showing more than 80% granulation tissue.⁵

Case series of pediatric and facial burn patients have also demonstrated that the VERSAJET System facilitated precise and controlled debridement in delicate contoured regions, successfully preparing the wound beds for the application of biological dressings. As a result, excellent adherence of the dressings was achieved, promoting optimal healing of the burn wounds.^3,18

Additionally, the VERSAJET System has been shown to provide effective wound bed preparation in patients with PIs and sub-acute or chronic wounds, leading to successful skin grafting.^11,19 Patients undergoing surgical repair of PIs following hydrosurgical debridement demonstrated no complications at 30-days post-operation and 100% survival of skin flaps and grafts (7/7; Figure 9).¹¹

In patients with sub-acute and chronic wounds, the VERSAJET System was reported to provide a smoother, more regular and consistent wound bed compared to sharp debridement. This facilitated immediate skin grafting, with total engraftment observed in 95% of patients (150/158; Figure 9).¹⁹

Healing time

Debridement with the VERSAJET System has been associated with a shorter healing time of wounds, compared with conventional surgical/sharp debridement or treatment with moist dressings.^23,24

In a study of minor amputation patients with DFUs, debridement with the VERSAJET System was associated with a significantly shorter mean healing time, compared with conventional surgical debridement combined with pulse lavage (p<0.05; Figure 10).²⁴ Mean healing time was also shown to be shorter following hydrosurgical debridement of thermal burns in rats, compared with conventional surgical debridement (p<0.05; Figure 10).²³ The surface area of the thermal burns debrided using the VERSAJET System was significantly smaller on days 2, 4, and 7 post-procedure, compared with wounds treated with conventional surgical debridement (p<0.01, p<0.05, and p<0.05, respectively).²³

Health Economic Outcomes

Number of repeat/additional procedures

Studies have demonstrated that, compared with conventional methods, fewer debridement procedures are required prior to wound closure and healing using the VERSAJET◊ System.^4,7,9,24,26 In many cases only one procedure was required to achieve adequate wound bed debridement.^5,13,30

A systematic literature review of seven studies assessing the treatment of chronic wounds with VERSAJET found that 86.3% of patients (220/255) were successfully treated with one procedure (Figure 11).³⁰ Several other studies in a variety of wound types, including burn wounds and DFUs, have found that the mean number of debridements required was lower when using the VERSAJET System, compared with conventional sharp debridement (all p≤0.05; Figure 11).^9,24,26 In patients with open tibia fractures, significantly fewer overall debridement procedures were required with the VERSAJET System, compared with conventional debridement (Figure 11).³¹

Instrument and resource use

The VERSAJET◊ System cuts and removes tissue with one instrument in one pass,^13,15,17,32 and therefore requires fewer instruments and resources, compared to surgical debridement with pulse lavage.²⁵

A prospective, randomized controlled clinical trial in lower extremity ulcers found that debridement using the VERSAJET System was performed with surgical trays containing fewer instruments and used significantly less saline (p<0.001), compared with surgical debridement with pulse lavage (Figure 12).²⁵

Operating room/debridement time

The VERSAJET System facilitates precise and efficient debridement of wounds and has been shown to deliver faster debridement of burns, ulcers, and chronic wounds, compared to sharp debridement (Figure 13).^10,25,27,28 This results in reduced time in the operating room, and as a result has the potential to increase the number of patients treated in a given operating session.²⁵

Mean debridement time has been shown to be significantly lower using the VERSAJET System, compared with conventional debridement, in lower extremity ulcers and delayed healing wounds (p=0.008 and p=0.033, respectively; Figure 13).^10,25 The time to debride 10% of the total surface area of burns has also been shown to be significantly shorter, compared with escharectomy (p=0.02; Figure 13).²⁷

The VERSAJET System has also been shown to reduce the average time to achieve complete chronic ulcer debridement compared to conventional moist dressings (1.3 days versus 4.3 days).¹³ The faster debridement time with the VERSAJET System has the potential to increase the number of patients treated in a scheduled operating session, compared to conventional surgical techniques, as demonstrated in a prospective study of lower extremity ulcers (n=41).²⁵

Treatment cost

Compared with other debridement methods, debridement with the VERSAJET◊ System has been shown to result in a reduction in resource use through reducing the number of repeat procedures, instrument use, operating time, readmission to hospital, and length of hospital stay.^{10,13,25,26,33–35} As a result, use of the VERSAJET System may be associated with lower debridement treatment costs, compared to other methods.^10,25,26,33

A study in chronic leg ulcers demonstrated that, compared with moist wound dressings, debridement with the VERSAJET System may be associated with a shorter average time to achieve a clean wound bed, with an equivalent reduction in the length of hospital stay (Figure 14).¹³ Use of the VERSAJET System for the debridement of DFUs has also been associated with a shorter inpatient stay compared with standard orthopedic debridements (12 patients, 19 DFUs; Figure 14).³⁵

The number of unplanned hospital readmissions due to surgical site infections (SSIs) has also been shown to be less frequent following debridement with hydrosurgery, compared with conventional debridement (with or without pulse lavage; p=0.003), potentially resulting in decreased treatment costs (Figure 15).³⁴

Several studies have demonstrated that, compared with other debridement methods, use of the VERSAJET System in chronic wounds may be associated with a reduction in inpatient hospitalization, operating room equipment required, initial procedure costs, and reduced treatment costs per patient, compared to conventional debridement methods (Figure 15).^{10,13,25,26,33,35}

Conclusions

The VERSAJET◊ System has been shown to achieve precise and controlled tissue removal in a wide range of wound types. These include acute and chronic wounds, DFUs, venous leg ulcers, PIs, and burns.^{2,3,5,6,8,12,14–17} The VERSAJET System is also suitable for use on delicate and contoured areas such as the face, feet, hands, and genitals.^2,8,15–17 Patients have reported acceptable and tolerable pain levels, and debridement using the VERSAJET System has been shown to reduce the bacterial load in target areas, compared with pre-debridement levels.^{4,10,13,21,22} Debridement using the VERSAJET System has also been shown to help provide an effective wound healing environment by successfully preparing wound beds for skin grafts and the application of biological dressings^{.3-7,11–14,16,18,19}

Comparative studies have demonstrated that patients undergoing debridement using the VERSAJET System have lower levels of pain, reduced intraoperative blood loss, and improved healing times, compared with conventional debridement patients and those treated with moist dressings (Table 1).^{1,5,9,10,13,20,23,24}

The VERSAJET System may also deliver favorable health economic outcomes, in terms of number of procedures, instrument use, and operating room time (Table 1).^{4,5,7,9,13,24–26,30} Debridement using the VERSAJET System has been shown to reduce the number of procedures required, debridement time, and length of hospital stay, compared with conventional surgical/sharp debridement^{10,13,25,26,33–35} and reduce instrument use compared with surgical debridement combined with pulse lavage.²⁵ As a result, the VERSAJET System may lead to lower treatment costs per patient, compared to other debridement methods.^10,25,26,33

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References:

1. Cao YL, Liu ZC, Chen XL. Efficacy of hydrosurgical excision combined with skin grafting in the treatment of deep partial-thickness and full-thickness burns: a two-year retrospective study. Burns. 2022 Jul 29. [Epub ahead of print]
2. Chammas MF, Jr., Gurunluoglu R, Carlsen SN, Molina W, Jr., Moore EE, Kim F. Surgical debridement of mineral pitch and nonviable penile tissue using water-jet power: a preliminary report. BJU Int. 2009;103:974–976.
3. Cubison TC, Pape SA, Jeffery SL. Dermal preservation using the VERSAJET hydrosurgery system for debridement of paediatric burns. Burns. 2006;32:714–720.
4. Edmondson S-J, Ali Jumabhoy I, Murray A. Time to start putting down the knife: a systematic review of burns excision tools of randomised and non-randomised trials. Burns. 2018;44:1721–1737.
5. Ferrer-Sola M, Sureda-Vidal H, Altimiras-Roset J, et al. Hydrosurgery as a safe and efficient debridement method in a clinical wound unit. J Wound Care. 2017;26:593–599.
6. Hyland EJ, D’Cruz R, Menon S, et al. Prospective, randomised controlled trial comparing VERSAJET™ hydrosurgery and conventional debridement of partial thickness paediatric burns. Burns. 2015;41:700–707.
7. Kakagia DD, Karadimas EJ. The efficacy of VERSAJET™ hydrosurgery system in burn surgery. A systematic review. J Burn Care Res. 2018;39:188–200.
8. Klein MB, Hunter S, Heimbach DM, et al. The VERSAJET water dissector: a new tool for tangential excision. J Burn Care Rehabil. 2005;26:483–487.
9. Legemate CM, Goei H, Gostelie OFE, Nijhuis THJ, van Baar ME, van der Vlies CH. Application of hydrosurgery for burn wound debridement: an 8-year cohort analysis. Burns. 2019;45:88–96.
10. Liu J, Ko JH, Secretov E, et al. Comparing the hydrosurgery system to conventional debridement techniques for the treatment of delayed healing wounds: a prospective, randomised clinical trial to investigate clinical efficacy and cost-effectiveness. Int Wound J. 2015;12:456–461.
11. Matsumine H, Giatsidis G, Takagi M, Kamei W, Shimizu M, Takeuchi M. Hydrosurgical debridement allows effective wound bed preparation of pressure injuries: a prospective case series. Plast Reconstr Surg Glob Open. 2020;8:e2921.
12. Matsumura H, Nozaki M, Watanabe K, et al. The estimation of tissue loss during tangential hydrosurgical debridement. Ann Plast Surg. 2012;69:521–525.
13. Mosti G, Mattaliano V. The debridement of chronic leg ulcers by means of a new, fluidjet-based device. Wounds. 2006;18:227–237.
14. Rees-Lee JE, Burge T, Estela C. The indications for VERSAJET® hydrosurgical debridement in burns. Eur J Plast Surg. 2008;31:165–170.
15. Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32:64–69.
16. Siemers F, Mauss KL, Liodaki E, Ottomann C, Bergmann PA, Mailänder P. Accidental inclusions following blast injury in esthetical zones: ablation by a hydrosurgery system. Eplasty. 2012;12:e33.
17. Sivrioğlu N, Irkören S. VERSAJET hydrosurgery system in the debridement of skin necrosis after Ca gluconate extravasation: report of 9 infantile cases. Acta Orthop Traumatol Turc. 2014;48:6–9.
18. Tenenhaus M, Bhavsar D, Rennekampff HO. Treatment of deep partial thickness and indeterminate depth facial burn wounds with water-jet debridement and a biosynthetic dressing. Injury. 2007;38:S39–S45.
19. Vanwijck R, Kaba L, Boland S, Gonzales y Azero M, Delange A, Tourbach S. Immediate skin grafting of sub-acute and chronic wounds debrided by hydrosurgery. J Plast Reconstr Aesthet Surg. 2010;63:544–549.
20. Yang JY, Hwuang JY, Chuang SS. Clinical experience in using the water jet in burn wound debridement. Ann Burns Fire Disasters. 2007;20:72–77.
21. Granick MS, Tenenhaus M, Knox KR, Ulm JP. Comparison of wound irrigation and tangential hydrodissection in bacterial clearance of contaminated wounds: results of a randomized, controlled clinical study. Ostomy Wound Manage. 2007;53:64–72.
22. Schwartz JA, Goss SG, Facchin F, Avdagic E, Lantis JC. Surgical debridement alone does not adequately reduce planktonic bioburden in chronic lower extremity wounds. J Wound Care. 2014;23:S4–S13.
23. Hirokawa E, Sato T, Fujino T, Gotoh Y, Yokogawa H, Ichioka S. Hydrosurgical debridement as an approach to wound healing: an animal thermal burn model. J Wound Care. 2019;28:304–311.
24. Smith+Nephew 2005. The use of VERSAJETTM in the limb salvage following failure of minor amputation in diabetic foot. Internal Report.
25. Caputo WJ, Beggs DJ, DeFede JL, Simm L, Dharma H. A prospective randomised controlled clinical trial comparing hydrosurgery debridement with conventional surgical debridement in lower extremity ulcers. Int Wound J. 2008;5:288–294.
26. Granick MS, Posnett J, Jacoby M, Noruthun S, Ganchi PA, Datiashvili RO. Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement. Wound Repair Regen. 2006;14:394–397.
27. Gravante G, Delogu D, Esposito G, Montone A. VERSAJET hydrosurgery versus classic escharectomy for burn débridment: a prospective randomized trial. J Burn Care Res. 2007;28:720–724.
28. McAleer JP, Kaplan EM, Persich G, Axman W. A prospective randomized study evaluating the time efficiency of the VERSAJET™ hydrosurgery system and traditional wound debridement. Poster presented at: American College of Foot and Ankle Surgeons (AFCAS) Annual Scientific Conference; March 9–13, 2005; New Orleans, LA.
29. Allan N, Olson M, Nagel D, Martin R. The impact of hydrosurgical debridement on wounds containing bacterial biofilms. Poster presented at: European Tissue Repair Society (ECTS) Annual Meeting; September 15–17, 2010; Ghent, Belgium.
30. Bekara F, Vitse J, Fluieraru S, et al. New techniques for wound management: a systematic review of their role in the management of chronic wounds. Arch Plast Surg. 2018;45:102–110.
31. Oosthuizen B, Mole T, Martin R, Myburgh JG. Comparison of standard surgical debridement versus the VERSAJET Plus™ hydrosurgery system in the treatment of open tibia fractures: a prospective open label randomized controlled trial. Int J Burns Trauma. 2014;4:53–58.
32. Hong CC, Nather A, Lee J, Mao HT. Hydrosurgery is effective for debridement of diabetic foot wounds. Ann Acad Med Singapore. 2014;43:395–399.
33. Granick MS, Jacoby M, Noruthrun S, Datiashvili RO, Ganchi PA. Clinical and economic impact of hydrosurgical debridement on chronic wounds. Wounds. 2006;18:35–39.
34. James CV, Patel M, Ilonzo N, et al. Hydrosurgical debridement use associated with decreased surgical site-related readmissions: a retrospective analysis. Wounds.33:139–142.
35. Murray F. The impact of the VERSAJET™ hydrosurgery system on number of procedures and length of inpatient episodes. Poster presented at: European Wound Management Association (EWMA) Conference; May 2–4, 2007; Glasgow, UK.