Hydrosurgery: Comparison With Alternative Debridement Methods

Summary

• Debridement is the process of removing dead or damaged tissue, foreign material, and debris from a wound and is recognized as a crucial component of effective wound management and healing.^1,2
•  Advantages of hydrosurgical debridement over conventional surgical/sharp debridement include preservation of dermis; all-in-one cutting, irrigation, and removal of debris; and higher-quality wound bed preparation.^3–26
• An advantage of hydrosurgical debridement over ultrasound debridement is the potential requirement for fewer procedures.^2,8,27 In addition, a disadvantage of ultrasound debridement is the time required to set up and clean up following the procedures.^27–29

What is debridement?

Debridement is the process of removing dead or damaged tissue, foreign material, and debris from a wound.¹ It is recognized as a crucial component of effective wound management and healing.²

By removing nonviable tissue, bacteria, and debris from a wound, debridement mitigates the risk of infection and encourages re-epithelialization, wound closure, and healing.³⁰ It facilitates wound bed preparation in a variety of acute and chronic wounds such as burns, open fractures, diabetic foot ulcers, leg ulcers, pressure ulcers, and surgical wounds.^1,27,31–35

Historically, several methods of wound debridement have been used in clinical practice.^{1,27,31,32,34} Conventional surgical/sharp debridement, ultrasound debridement and hydrosurgical debridement are examples of methods currently used.^1,27

The ideal debridement method should spare as much viable tissue as possible, be completed as quickly as possible, minimize the need for repeat procedures, cause minimal blood loss, yield a low risk of infection, and be resource-efficient and cost-effective.^2,35

Overview of debridement methods

Conventional surgical/sharp debridement

Surgical debridement and sharp debridement are two distinct but highly similar forms of debridement, often referred to as two forms of conventional debridement.^2,17,27 They involve the sharp tangential excision of nonviable tissue with a specialized hand-held knife, scissors, or a simple scalpel (Figure 1).^1,16,27,35

Surgical debridement involves the aggressive excision of devitalized tissue by a surgeon in the sterile environment of an operating theater. It is associated with bleeding, the excision of healthy tissue, and a high level of pain, requiring the administration of anesthetic.^1,27

Sharp debridement involves the excision of small quantities of dead tissue, using scissors or a scalpel, with comparatively limited pain or bleeding. It does not require anesthetic and may be performed in a community setting (at home or in a community clinic), as well as in hospital.^1,27,36

This paper refers to surgical and sharp debridement collectively as surgical/sharp debridement and understands conventional debridement to encompass both methods.

Although surgical/sharp debridement is typically viewed as the gold standard in debridement, it has several disadvantages.^2,17,27 It tends to involve the excision of viable tissue due to a lack of selectivity, thereby hindering the natural wound healing process.^17,27 It may sometimes lead to an uneven wound bed, which hinders immediate skin grafting.^2,26 Moreover, in the case of surgical debridement, the procedure is painful, requiring hospital admission and anesthetic.²⁷

Ultrasound debridement

Ultrasound therapy in wound healing may involve the use of low-frequency or high-frequency ultrasound, delivered with or without direct contact (via saline as a coupling medium) between the ultrasound device and the wound.³⁷ Ultrasound debridement, more specifically, typically involves the use of a specialized device to transmit low-frequency ultrasound waves directly to tissue through a saline conduit (Figure 1).^2,38 Hence, this paper considers only low-frequency, contact ultrasound.

The mechanisms by which ultrasound waves may enhance the tissue repair process during debridement have not yet been fully elucidated, but it is understood that they cause vibrations and secondary pressure changes within the targeted area, removing devitalized tissue through acoustic cavitation and microstreaming.^2,38,39 Its efficacy is thought to derive in part from the upregulation of cellular activity, including growth factor synthesis, as well as potential disruption to the bacterial biofilm and increased bacterial susceptibility to antibiotics.^29,38,40

• Cavitation involves the formation and implosion of micron-sized bubbles in the target tissues, caused by the absorption of ultrasound energy by individual protein molecules, which leads to changes in cell function²
• Microstreaming occurs when fluids move along sound wave boundaries, such as cell membranes, resulting in increased protein synthesis and increased permeability of the cell membranes and vascular walls²

A systematic literature review (SLR) has shown that ultrasound debridement can enable reductions in healing time and operating time compared to surgical/sharp debridement.² Limitations of ultrasound debridement, however, include the requirement for maintenance debridement (involving as many as ten procedures), the need for advanced skill training, and a long setup time.²⁷

Hydrosurgical debridement

Hydrosurgery involves the emission of a high-pressure jet of sterile saline across an aperture that causes a localized vacuum to cut tissue, irrigate the wound, and remove debris simultaneously (Figure 1).^12,19,22,25 Hydrosurgical debridement offers several advantages over both conventional surgical/sharp debridement and ultrasound debridement, as described below.

Advantages of hydrosurgery versus surgical/sharp debridement

Based on its unique features, hydrosurgery offers several advantages over conventional surgical/sharp debridement, resulting in improved clinical and health economic outcomes.^3–26

Advantage 1: Preservation of dermis

In surgical/sharp debridement, the surgeon excises nonviable tissue until bleeding tissue is encountered, as this is a marker of vital tissue. Consequently, there is a high likelihood of viable tissue loss.^13,16 Hydrosurgical debridement achieves preservation of viable dermis because it lifts only nonviable tissue, which implodes when exposed to the power of the saline jet.^7,16

Hydrosurgical debridement may therefore help to achieve better scar quality than conventional surgical/sharp debridement, given that loss of dermis is understood to be one of the main factors determining the quality of a scar.^3,16 The increased preservation of viable tissue in hydrosurgical debridement may also contribute to reduced intraoperative blood loss and a lower mean volume of blood transfusion compared to surgical/sharp debridement.^3,11,15,17

Enhanced dermal preservation may also underlie evidence that hydrosurgery results in reduced wound healing time compared to conventional debridement* and yields tolerable levels of pain, ranging from mild to moderate.^8,11,19,20 Relatedly, hydrosurgery is capable of achieving controlled excision from wounds in a variety of distinctive and delicate locations, including complex contoured areas, web spaces, and facial structures.^{5,14,22,24,25}

* Debridement of stub dehiscence following minor amputation in diabetic patients (n=24) and an animal thermal burn model.

Advantage 2: All-in-one tool for cutting, irrigation, and removal of debris

Hydrosurgical debridement involves a single tool that simultaneously cuts tissue, irrigates a wound, and removes debris.^12,19,22,25 By contrast, achieving a similarly clean wound with surgical/sharp debridement may necessitate the separate use of pulse lavage to irrigate the wound and remove cellular debris afterwards.⁴

The all-in-one nature of the hydrosurgical tool brings numerous benefits. Hydrosurgical debridement is faster than surgical/sharp debridement because there is no need to change tools for debridement, and the high-speed saline jet means that a clean surgical field, less bloody than with conventional debridement, is always available.^{4,6,10,17,18,21} With hydrosurgical debridement, no pulse lavage equipment is necessary; the use of saline in hydrosurgical debridement is much more efficient than with pulse lavage in conventional surgical/sharp debridement, resulting in a considerable reduction in the volume of saline used per procedure.⁴ There is no need to open a major instrument tray with hydrosurgical debridement, leading to more efficient use of time by operating room staff and faster turnover between cases.^4,9,10

Due to its avoidance of pulse lavage, shorter debridement time, reduction in saline usage, and use of a smaller instrument tray, hydrosurgery can also bring about cost savings compared to surgical/sharp debridement.^4,9,10,17

Advantage 3: Higher-quality wound bed preparation

Hydrosurgical debridement achieves a high quality of debridement. The quality of the wound bed obtained with hydrosurgery creates a smoother, less irregular wound surface than with conventional surgical/sharp debridement, which renders the wound ready to receive a skin graft as required.^23,26

In chronic wounds, multiple sessions of conventional debridement are often needed to achieve adequate wound bed preparation.^10,20 Hydrosurgery, however, has been shown to achieve effective debridement of a wound in a single procedure in over 70% of cases.^†,8 As above, the association of hydrosurgery with fewer debridement procedures and a shorter overall excision time can lead to considerable cost savings compared to surgical/sharp debridement.^10,17

Advantages of hydrosurgery versus ultrasound debridement

Hydrosurgery may also offer advantages over ultrasound debridement based on its distinctive characteristics.^{2,4,8,10,27–29}

Advantage 1: Fewer procedures

Using hydrosurgery, a single procedure has been shown to be sufficient to achieve adequate wound bed debridement.^†,8 For ultrasound debridement, by contrast, maintenance debridement procedures are required.²⁷ The number of required procedures varies considerably across patients; studies have reported the requirement for up to ten procedures in some patients.²

Advantage 2: Simpler, quicker setup and ease of use

The complexity of the ultrasound apparatus setup is a notable limitation of the method.^27–29 Ultrasound debridement requires a relatively long setup and clean-up time, involving sterilization of the specialized handpieces, compared to sharp debridement.^27–29 It also necessitates advanced skill training, including specialist training in a variety of settings.^27,28

In contrast to ultrasound debridement, hydrosurgical debridement utilizes a disposable handpiece.⁴ It has been characterized as quick and easy to perform, with any surgeon skilled in surgical debridement capable of developing rapid proficiency in the use of the hydrosurgical device.¹⁰

† n=39, 53 wounds.

Conclusions

Hydrosurgery involves the emission of a high-pressure jet of sterile saline across an aperture that causes a localized vacuum to cut tissue, irrigate a wound, and remove debris simultaneously.^12,19,22,25 Hydrosurgical debridement offers several advantages over both conventional surgical/sharp debridement and ultrasound debridement.^2–29

Compared to conventional surgical/sharp debridement, the advantages of hydrosurgical debridement are preservation of dermis; all-in-one cutting, irrigation, and removal of debris; and higher-quality wound bed preparation.^3–26

Compared to ultrasound debridement, hydrosurgical debridement offers key advantages of requiring fewer procedures and a simpler, quicker setup.^{2,4,8,10,27–29}

References:

1.  Smith F, Dryburgh N, Donaldson J, Mitchell M. Debridement for surgical wounds. Cochrane Database Syst Rev. 2013;9:CD006214.
2.  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.
3.  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]
4.  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.
5. 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.
6.  Cubison TC, Pape SA, Jeffery SL. Dermal preservation using the Versajet hydrosurgery system for debridement of paediatric burns. Burns. 2006;32:714–720.
7.  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.
8.  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.
9.  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.
10.  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.
11. 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.
12. Hong CC, Nather A, Lee JK, Mao HT. Hydrosurgery is effective for debridement of diabetic foot wounds. Ann Acad Med Singap. 2014;43:395–399.
13. 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.
14. 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.
15.  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.
16.  Legemate CM, Kwa KAA, Goei H, et al. Hydrosurgical and conventional debridement of burns: randomized clinical trial. Br J Surg. 2022;109:332–339.
17.  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.
18.  McAleer JP, Kaplan EM, Perisich 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.
19.  Mosti G, Mattaliano V. The debridement of chronic leg ulcers by means of a new, fluidjet-based device. Wounds. 2006;18:227–237.
20.  Smith+Nephew 2005. The use of VERSAJET™ in the limb salvage following failure of minor amputation in diabetic foot. Internal Report.
21.  Rees-Lee JE, Burge T, Estela C. The indications for VERSAJETR hydrosurgical debridement in burns. Eur J Plast Surg. 2008;31:165–170.
22.  Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32:64–69.
23.  Shimada K, Ojima Y, Ida Y, Matsumura H. Efficacy of VERSAJET hydrosurgery system in chronic wounds: a systematic review. Int Wound J. 2021;18:269–278.
24.  Siemers F, Mauss KL, Liodaki E, Ottomann C, Bergmann PA, Mailander P. Accidental inclusions following blast injury in esthetical zones: ablation by a hydrosurgery system. Eplasty. 2012;12:e33.
25.  Sivrioğlu N, Irkoren 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.
26.  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.
27. Thomas DC, Tsu CL, Nain RA, Arsat N, Fun SS, Sahid Nik Lah NA. The role of debridement in wound bed preparation in chronic wound: a narrative review. Ann Med Surg (Lond). 2021;71:102876.
28. Vowden K, Vowden P. Debridement made easy. Wounds UK. 2011;7.
29. Wendelken M, Markowitz L, Alvarez O. A closer look at ultrasonic debridement. Pod Today. 2010;23:42–48.
30. Manna B, Nahirniak P, Morrison CA. Wound Debridement. Treasure Island, FL: StatPearls Publishing; 2022.
31. Cornell RS, Meyr AJ, Steinberg JS, Attinger CE. Debridement of the noninfected wound. J Vasc Surg. 2010;52:31S–36S.
32. Elraiyah T, Domecq JP, Prutsky G, et al. A systematic review and meta-analysis of debridement methods for chronic diabetic foot ulcers. J Vasc Surg. 2016;63:37S–45S.e2.
33. Giannoudis PV, Papakostidis C, Roberts C. A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br. 2006;88-B:281–289.
34. Kwa KAA, Goei H, Breederveld RS, Middelkoop E, van der Vlies CH, van Baar ME. A systematic review on surgical and nonsurgical debridement techniques of burn wounds. J Plast Reconstr Aesthet Surg. 2019;72:1752–1762.
35. Wormald JC, Wade RG, Dunne JA, Collins DP, Jain A. Hydrosurgical debridement versus conventional surgical debridement for acute partial-thickness burns. Cochrane Database Syst Rev. 2020;9:CD012826.
36. O’Brien M. Debridement: ethical, legal and practical considerations. Br J Community Nurs. 2003;8:S23–S25.
37. Madhok BM, Vowden K, Vowden P. New techniques for wound debridement. Int Wound J. 2013;10:247–251.
38. Chang YR, Perry J, Cross K. Low-frequency ultrasound debridement in chronic wound healing: a systematic review of current evidence. Plast Surg (Oakv). 2017;25:21–26.
39. Michailidis L, Bergin SM, Haines TP, Williams CM. A systematic review to compare the effect of low-frequency ultrasonic versus nonsurgical sharp debridement on the healing rate of chronic diabetes-related foot ulcers. Ostomy Wound Manage. 2018;64:39–46.
40. Conner-Kerr T, Alston G, Stovall A, et al. The effects of low-frequency ultrasound (35 kHz) on methicillin-resistant Staphylococcus aureus (MRSA) in vitro. Ostomy Wound Manage. 2010;56:32–43.