Hydrosurgery: Key Features and Clinical Applications

Summary

• Hydrosurgery is a method for precisely and tangentially excising nonviable or necrotic tissue using a high-powered jet of fluid while simultaneously clearing away bacteria and debris.^1–12
• Hydrosurgery is indicated for use in a variety of applications, including discectomy, spinal fusion preparation, tenotomy, and wound debridement or wound bed preparation.^{2,6,7,9,11,13–25}
• The control provided by the high-powered fluid jet and the ability to continuously clear away contaminants enable precise targeting of nonviable tissue and preservation of healthy tissue.^{4,6,8,17,18,26}

What Is Hydrosurgery?
Hydrosurgery is a method for removing tissue with a jet of fluid used as a dissecting tool. In practice, this controlled, high-pressure jet of sterile saline may be used to tangentially excise nonviable or necrotic tissue and prepare a wound surface or surgical site for closure or grafting, all while preserving healthy tissue.^4,6,8,11,26

A hydrosurgical device consists of a reusable power console and a single-use sterile handpiece and tubing assembly. The pressure of the stream of sterile saline generated from a nozzle at the end of the handpiece can be adjusted to allow for fine to aggressive controlled tissue excision.^2,11,27 The pressurized sterile saline stream cuts away damaged tissue and contaminants while simultaneously irrigating the wound (Figure 1).^2,4,7,9

 Hydrosurgery allows for tissue to be simultaneously cut and removed in a single pass.^9,11,28,29 Throughout the process, irrigation fluid from the saline jet and waste are continuously vacuumed into a container; this may minimize splash and saturation of the target area, resulting in negligible aerosolization of bacteria,* and facilitate clear visualization of the wound or surgical area.^{†,1,2,4,5,7,9,10,30}

* Demonstrated in an ex vivo inoculated porcine model.
† Unlike pulse lavage, which may drive fluid containing bacteria deeper into the wound bed, as demonstrated in vivo.

Clinical Applications
Hydrosurgery is indicated for use in a variety of clinical procedures, including discectomy, spinal fusion preparation, and tenotomy.^{14,17,18,23,24,31} Furthermore, it is used as a debridement method for wounds which, by a physician’s judgment, would traditionally require conventional surgical/sharp debridement;²¹ hydrosurgery grants a high degree of precision and control in the removal of necrotic tissue and wound bed preparation, helping to preserve viable tissue.^6,8,11

Discectomy
Hydrosurgery may be utilized for a variety of disc decompression procedures including percutaneous decompression for contained disc herniations and microdiscectomy (Figure 2).^14,24,32 The controlled velocity of the saline stream has been shown to enable the precise removal of disc material and helps to avoid damage to other structures.^17,32 It is claimed that disc decompression procedures using hydrosurgery may be performed under local anesthesia, and the minimally invasive nature of the procedure may help to reduce the risk of re-herniations and other complications.³²

Spinal fusion preparation
Hydrosurgery has been shown to effectively prepare the intervertebral disc space for graft implantation during open lumbar interbody fusion procedures (Figure 2).^‡,17,23 Hydrosurgery has been reported to remove substantially more unwanted disc tissue than conventional techniques, requiring less instrument use over a shorter duration of time.^‡,17 Additionally, the technique may allow for precise endplate preparation while avoiding damage to the bony endplate.^‡,17

Tenotomy
Hydrosurgery may be used to resect and evacuate tendinopathic tissue in an outpatient setting using a high velocity jet of fluid, allowing for tissue-selective resection of nonviable tendon tissue (Figure 2).^‡,18 Hydrosurgical tenotomy may be used to provide pain relief and treat tendon thickening and degeneration in patients with chronic tendinosis while preserving healthy tissue.³¹
‡ Human cadaveric study.

Wound Debridement
Wound debridement is recognized as a crucial component of effective wound management and healing.³⁴ By removing nonviable tissue, bacteria, and debris from a wound, debridement encourages re-epithelialization, wound closure, and healing.^34,35 Historically, several methods of wound debridement have been used in clinical practice, including autolytic, enzymatic, biological, mechanical, and conventional surgical/sharp;³⁴ hydrosurgery is an alternative method to surgical or sharp debridement.

The precision and power of the saline stream enables targeted excision of nonviable tissue from wounds and preservation of healthy tissue,^6,8,11 facilitating wound bed preparation in a variety of acute and chronic wounds such as burns, open fractures, pressure injuries, diabetic foot ulcers, venous leg ulcers, and ulcers caused by arterial insufficiency.^{2,6,7,11,13,15,16,19,20,36–38} The accuracy and control provided by hydrosurgery are particularly evident in soft tissue removal from contoured spaces such as the face, feet, hands, web spaces, and genitals.^{11,29,39–41} The continuous saline stream coupled with the vacuum component maintain a clean surgical field, less bloody than with conventional debridement, and consistently clear away debris and bacteria, enabling rapid debridement (Figure 3).^{2,7,9,13,20,22} 

The highly selective nature of hydrosurgery and the effective removal of contaminants during the debridement process also facilitate optimal wound bed preparation in wounds requiring repair by skin grafts or reconstructive surgery.^4,25,42 This effect has been previously demonstrated in traumatic scalp, arm, elbow, and thigh wounds.⁴ Hydrosurgery is able to obtain a wound bed with a smooth, regular surface, which may allow for immediate skin grafting after a single debridement procedure.^9,25
 

Key Clinical and Health Economic Attributes of Hydrosurgical Wound Debridement

Hydrosurgery grants clinicians a high level of precision and control when excising tissue and clearing away bacteria and debris; this results in positive clinical and health economic outcomes across a range of applications, which are summarized below. Further details regarding these outcomes are available in Chapter 4.

^§ n=24.
** As demonstrated in vivo.
^{† †} n=40.
* Demonstrated in an ex vivo inoculated porcine model.

In summary, hydrosurgical wound debridement can yield positive clinical outcomes with respect to viable tissue preservation, pain, bleeding, bacterial burden, wound bed preparation, and healing time. It may also yield positive health economic outcomes in terms of number of procedures, instrument use, and operating room time.

Conclusions
Hydrosurgery is a well tolerated and effective method of tissue excision.^{6,8,9,14,17,18,22–24,31,37} It has demonstrated the ability to precisely target and remove tissue in a broad range of clinical applications such as disc decompression procedures, spinal fusion preparation, and tenotomy.^14,17,18,23 In addition, hydrosurgery is an alternative to surgical or sharp debridement, demonstrating effectiveness at tangentially cutting away necrotic tissue and preparing a wound for closure and healing.^{4,6–8,11,13,22,25,36,37,42}

Unique features such as the adjustable pressurized sterile saline stream and continuously vacuumed irrigation fluid differentiate hydrosurgical wound debridement from other techniques and result in positive clinical and health economic outcomes.^{2,3,6-13,20,22,25,26,29,30,37,39-41,43,45–47}

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