Use of a Novel Hydrosurgery Device in Surgical Debridement of Difficult-to-heal Wounds

Wound management is a substantial clinical and economic issue. Difficult wounds significantly affect the socioeconomic costs, and the progressive increase in population lifespan further accounts for the impact on health care spending.^1–3 Today, clinicians share with patients a legitimate demand to limit the consequences of prolonged and/or important morbidity due to complex wounds, whether they are chronic or acute. This raises a compelling need to optimize wound care and requires simple, rapid, and safe treatment for all wound types. Exploitation of the insights coming from research is fundamental to the development and implementation of standard care procedures that may optimize the wound healing potential.
The research into wound healing has laid the path for the evolution of some principles of wound care, especially in relation to the wound bed preparation (WBP). Wound bed preparation is an essential process in accelerating endogenous healing or facilitating the effectiveness of other therapeutic measures. Wound bed preparation considers the removal of local barriers to healing through the T.I.M.E. principles (Tissue management; Infection or Inflammation control; Moisture balance; Epithelization) by optimizing debridement, reduction of bioburden, and exudate management, as integral parts of preparing the wound bed.^4,5
According to WBP, removal of necrotic burden by debridement is a key step in wound management. Devitalized tissue may hinder the assessment of the wound depth or the conditions of the perilesional tissue; necrotic burden can be a breeding ground for bacteria and prevents healing, and concealed dead spaces may harbor bacteria that further contribute to tissue damage.^4,6 Therefore, an efficient wound bed debridement technique that can decrease wound contamination and remove cell debris thereby limits tissue destruction, and is a mandatory step to advance the healing process. Surgical (or sharp) debridement is the most efficient way to remove debris and necrotic tissue. Conventional sharp techniques are mostly performed in difficult and traumatic wounds and are multi-step procedures where initial debridement to remove necrotic or non-vital tissue is followed by a pulsed saline lavage of the wound area that is followed by further debridement of any unconcealed dead tissue. The length of this procedure may be complicated by splashing of irrigant and droplet aerosolization that may occur during the irrigation phase, with resulting limitations on the visibility and potential hazard risks for the operators. Moreover, surgical debridement requires some degree of skill to avoid aggravating the wound, as well as the hospitalization and follow-up of the patient, and is not indicated for patients with bleeding disorders.⁴
Waterjet (or fluidjet) dissection has been practiced in surgery for many years due to its ease of use, hemostatic quality, and rapid technique, which leads to less complications.^7–9 The Versajet^™ Hydrosurgery System (Smith & Nephew, Hull, UK) is a hydrosurgical device based on fluidjet technology that uses the Venturi effect and creates a high-pressure water jet stream that is capable of cutting tissue, while the debris is aspirated into a suction receptacle. Due to its advantages of in terms of precision, speed, and safety, this system is believed to be useful in the excision of difficult wounds.^6,10–17
The authors report on the use of this hydrosurgery system in patients presenting with a variety of difficult chronic and acute lesions of different etiologies.

Material and Methods
Apparatus. The fluidjet equipment consists of a power console that is controlled by a foot pedal, a disposable handpiece, a bag of saline (the fluid irrigant) that is connected to the power console with pressure tubing, and a waste container for effluent. The power console propels the highly pressurized saline through the tip of the handpiece; the saline is collected by the collector device and creates a localized vacuum—the Venturi effect. The fluidjet tip excises the unwanted tissues, while the vacuum aspirates the debris at the suction point.
The power setting is adjustable and is used to regulate the cutting power. The pressure the operator exerts on the tissues can also influence the depth of dissection.

The handpiece is available with either a 8-mm or 14-mm operating window and with either a 45- or 15-degree angle (14-mm handpiece only). Handpiece orientation relative to the tissue determines the effect on the tissue (Figure 1). When the handpiece is oriented parallel to the wound bed the primary effect is the excision, while orienting the handpiece obliquely to the tissue mainly results in irrigation and aspiration.^4,8
According to device’s product information, the standard 45-degree handpiece is suitable for use outside the operating room environment, such as examination rooms or at patient bedside, provided the floor immediately surrounding the treatment area is covered and any splashes are cleaned immediately after treatment is complete. In contrast, the 15-degree, 14-mm standard handpiece should not be used outside the operating room due to the potential for excessive misting or spraying.
Patient selection. The hydrosurgery system was used in 16 patients aged 35 years to 80 years with wounds of different etiologies (eg, necrotic, infected, traumatic, chronic wounds, burns, and post-surgical wounds). In 5 cases, the lesions (3 on the foot and 2 on an inferior limb) were of diabetic etiology, trauma (6 cases), burn (3 cases), cutaneous carcinoma (1 case), and venous disease (1 case). Details on patient characteristics and the procedures performed in these case reports are shown in Table 1.

All patients were informed of the potential risks and benefits associated with the procedure and signed a consent form.
When practicable, debridement was performed on an outpatient basis, or at the patient’s bedside. Local anesthesia was administered in cases of particularly painful wounds. Debridement was performed under general anesthesia in the surgical theater (or in the intensive care unit, if necessary) in cases of large, necrotic, painful wounds.
The hydrosurgery system was used to remove necrotic tissue and infection from the wound bed, for debridement of the granulation tissue and, if necessary, for the cleansing of exposed tendons.
In burn cases the device was used to elevate, debride, lavage, and resect the eschar. In some cases of eschar excision the hydrosurgery system was utilized in combination with a dermatome. The hydrosurgery system was also employed for defatting skin flaps before grafting.
Sometimes, mostly in cases where a positive swab test was obtained, it was deemed appropriate to mix an antibiotic with the saline for irrigation, to allow for wound lavage with an antibiotic solution while using the hydrosurgery system.
After wound debridement was completed, the affected area was covered with an adequate dressing; alternatively, depending on the wound conditions, debridement was followed by other techniques of wound closure, such as skin grafting, use of dermal substitutes, V.A.C.^® (KCI, San Antonio, Tex), or treated by secondary intention.

Results
Figures 2–4 illustrate wound condition before, during, and after treatment of the selected case reports detailed in Table 1.

Discussion
As other clinicians have observed,¹⁰ this hydrosurgery system is a fairly new apparatus for dissection and has a modest learning curve for setup and use. A rather short training session is sufficient to reach an adequate level of skill and confidence for power setting regulation and contact pressure applied to the tissue, which allows for proper dissection even in small, delicate, or swollen areas. All debridement was performed under direct vision, with the only exception in case of wound cavities, where particular caution was required to prevent the harm of important structures, such as vessels and nerves.
In the authors’ experience, the hydrosurgery system facilitated selective debridement of unwanted and damaged tissues in many wound types. After debridement the wound bed was well prepared for skin grafting or use of dermal substitutes, and in many cases, the quality of debridement prepared the wound bed for closure after a single debridement procedure or, at most, after a short period of treatment with advanced wound dressings or auxiliary devices.
The speed of this method over traditional surgical debridement reduced the operating time.¹⁷ The authors estimated that the average time per hydrosurgical procedure was 15 minutes. The highly selective system did not cause pain in cases of diabetic ulcers or wounds with abundant fibrin deposits, and therefore did not require anesthesia. Debridement of dry eschars appeared to be rather problematic and was assisted by prior softening with either enzymatic or autolytic treatment, or partial removal.
Using the hydrosurgery system, there was poor bleeding of the wound bed, and a simple application of adrenalin-embedded gauze pads was usually effective in achieving hemostasis. Therefore, the use of electrocautery was limited, thereby avoiding further tissue damage electrocauterization can cause.

In cases of decubitus ulcers, debridement with the hydrosurgery system was fundamental in preparing for reconstructive skin grafts or flaps. In cases of ischemic ulcers, this system avoided conventional sharp debridement, which can (in the authors’ experience) worsen the wound depth. In contaminated wounds and in partial-thickness depth burns (asphalt burns), the hydrosurgery system could be used as a dermabrader. Debridement using this system could also help in the management of high-energy soft tissue wounds. Surgical defatting of skin flaps for grafting is a peculiar application of the hydrosurgery system in that it facilitates uniform flap defatting and reduces the amount the flap is handled, thus traumatizing the tissue less.
In the authors’ experience, the use of the hydrosurgery system for the management of chronic and acute necrotic wounds presented some advantages over conventional methods of surgical debridement. In accord with other clinicians,^6,16 the authors found in cases of infected wounds that the suction the fluidjet exerts while removing the infected tissue from the site of the wound could prevent infected materials from being dragged deeper into the wound, which might occur when debriding with a scalpel. The suction action facilitated delicate stability on tissues that could not be readily held with forceps, such as fragile granulating tissue, or infected tendons. Moreover, tissue swelling did not occur as it might during pulsed lavage.
The use of the hydrosurgery system could have a prognostic value, as it facilitated gradual selectivity in reaching vital tissues, layer after layer. During debridement, bleeding is a signal indicating that all unwanted tissue has been removed and vital tissue has been reached; however, it is important to reach this goal while avoiding excessive bleeding. With respect to a standard sharp debridement, the precision and flexibility of this system allowed the debridement and a formation of a smooth surface of the wound bed in a more controlled manner— the procedure was fast, did not enlarge the wound, and prevented damage to vessels while sparing healthy tissue.
Dermal tissue preservation is of particular importance in cases of deep burns,¹⁵ where any small area of vital dermis may discriminate between quicker healing with a better aesthetic outcome and a slower healing with poor aesthetic outcomes. Moreover, the selectivity of the hydrosurgery system makes it ideal for use in areas with poor dermis or delicate structures, such as the hand.
The selection of different handpieces, the ability to regulate the most adequate power, and the handpiece orientation in relation to the tissue type, make the use of the hydrosurgery system suitable for debriding wounds that are quite difficult to handle, such as gunshot wounds, and undermined or tunneling wounds. The versatility of the device also allows the clinician to manage degloving wounds with massive tissue avulsion and cavities before skin grafting.
Lastly, the suction action of the hydrosurgery system, by continuously removing blood and material within the operating window, ensures a consistently clean operating field and improves visibility, thus allowing the surgeon to optimize technique and selectivity. Moreover, this system reduced the risk of potential contamination that can occur with splashing of the irrigant during pulse lavage.

Conclusion
Precision of the fluidjet, as well as its ability to cut selectively and ability to create a smooth surface while minimizing tissue damage, are features that render this system suitable for surgical debridement of a variety of difficult wounds, and especially for preparation of advanced wound healing techniques. Debridement with the hydrosurgery system leaves a well vascularized wound bed, thoroughly cleansed of necrotic debris and infection, and preserves the healthy tissue: thus, it can increase the potential for accelerating the endogenous wound healing or the effectiveness of other therapeutic measures, such as advanced wound healing and/or adjuvant treatments (eg, negative pressure wound therapy or hyperbaric therapy).
The authors believe this hydrosurgery system represents a selective and innovative debridement tool. Since it allows for better control and can reduce collateral damage, it may achieve overall better outcomes compared to conventional debridement techniques.