Centrifugal Debridement Using Advanced Surgical Technology

Modern literature on debridement initially centered on the life-saving benefits of debriding wounds sustained during war. The impact of debridement on decreasing war wound-related mortality was so profound that a century ago the concept of radical debridement became a dogmatic imprint on surgical mentality that has only recently been challenged.1,2

Traditional surgical debridement involves a centripetal technique: extirpation of the wound including a margin of healthy tissue. The goal of surgery is to eradicate all necrotic tissue and debris. In some wounds, which may track subcutaneously, surgery begins at a distance from the wound to encompass all affected tissue; debridement is accomplished in an ablative approach similar to how surgeons treat tumors. This is an effective technique and has saved many lives and healed many wounds during the last century.

We now can do better. Over the past few decades, a series of advanced therapeutic options have emerged to facilitate wound healing. Wound specialists who can optimally and effectively utilize these treatments similarly have emerged. This has resulted in a complex field of medicine involving many specialties — all of which play a role in healing a variety of challenging wounds. The wound clinic coordinates all of these options to provide the best possible care.

A new approach
Debridement in chronic wounds is an effort to remove necrotic or dysfunctional tissue, control bacterial load, restore moisture balance, and facilitate the healing wound edge in an attempt to convert the physiologic status of the wound surface to a state primed for subsequent healing. Debridement in acute wounds similarly is aimed at removal of necrotic and severely damaged tissues along with any foreign material.

Four years ago, an advanced surgical technology, the Versajet® (Smith & Nephew, Largo, Fla) — a high-pressure parallel water jet — was introduced,3 subsequently causing a paradigm shift in surgical wound management. This device utilizes a powerful stream of saline to precisely ablate tissue tangentially to a wound surface. The Venturi effect allows all of the fluid and debris to be removed from the field by a relative vacuum. Just as topical growth factors and living skin equivalents have compelled medical wound experts to re-evaluate wound management and develop concepts of wound bed preparation, the parallel water jet has brought focus to the role of surgery in wound management.

The water jet system facilitates a centrifugal procedure, a technique philosophically similar to tangential excision of burns. However, burns are on the body surface of the patient and tangential excision is concerned with a largely two-dimensional wound. Most non-burn wounds have a more three-dimensional configuration with depth and irregularities. Utilizing the new technology, surgeons can now debride from the inside of a wound and follow the pattern of necrosis to its limits without sacrificing normal adjacent tissue.

The high-pressure parallel water jet is a hand-held device, connected via tubing to a small, powerful pump that delivers a stream of saline of up to 15,000 psi. This focused beam of energized saline is directed parallel to the wound surface, vaporizing all tissue that it crosses and removing all of the fluid and debris. This allows the surgeon to precisely pare away unhealthy tissue from inside the wound until the border with healthy tissue is apparent (healthy tissue has a distinct appearance readily identified by surgeons). At that point, the debridement ends. This results in a more complete removal of unwanted necrotic or marginally viable tissue and the ability to maximize preservation of healthy collateral tissue.5,6 Bacterial load is reduced concomitantly.7 The end result is a healthier wound that requires fewer debridements8,9 and leaves more normal tissue intact — a profound improvement in surgical technique that is rapidly changing the way that surgeons approach wounds.
As medical and surgical wound experts increase focus on wound bed preparation, they realize that while their tools and approaches may be different, their goals are identical.

Debridement in a wound clinic
Performing debridement in a wound center depends on the wound and the patient. Perhaps most important is an awareness of all the options that may help the patient heal. The most commonly treated wounds in a wound center are diabetic foot ulcers, venous ulcers, and pressure ulcers. All of these wounds require preparation of the wound bed in order to have the best chance to heal secondarily or to be successfully closed surgically. Debridement options include autolysis, biological, mechanical, or enzymatic treatments. While all of these are effective in the right setting, it is important to remember that surgery achieves all of these objectives much more predictably, rapidly, and precisely, particularly when advanced technology such as the water jet is used.

In the appropriate clinical setting, surgical curettage; shaving and paring with a scalpel; and ultrasound treatment are easy, safe, and effective. When more extensive debridement is required, the patient needs to have surgery in the OR. The next big advance for wound clinics will be the introduction of a lower-powered, more affordable water jet system for outpatient use. In the meantime, appropriately incorporating a regular program of wound debridement during each clinic visit is imperative. Surgical consultation on complex poorly responding wounds, particularly with surgeons familiar with the latest technology, is advised.

Dr. Granick is a Professor of Surgery, tenured, and Chief and Program Director of Plastic Surgery, New Jersey Medical School-UMDNJ, Newark, NJ; and a medical consultant for Smith & Nephew, Largo, Fla. Please address correspondence to: mgranickmd@umdnj.edu.