Wound Bed Preparation for Capsulectomy Using a Hydrosurgery System

Introduction. Wound bed preparation is necessary for proper wound healing. Case Report. The case of a 75-year-old man with good outcomes after using a hydrosurgery system for capsulectomy is presented. At a 2-month follow-up visit, a fistula measuring 15 cm x 10 cm was found to have developed in the patient’s left scapular region after the first wide-excision surgery for soft tissue sarcoma and reconstruction of the defect using a local flap. The wound had fluid collection and a capsule that was then debrided with a hydrosurgery system. Since no infection was detected, closure with a pedicled latissimus dorsi (LD) muscle flap (15 cm x 6 cm) was performed. Due to persistent fluid collection, the LD harvest site had to be drained after discharge (18 days postoperatively); however, in the regions debrided by the hydrosurgery system, the suction drain could be removed early. Conclusions. In the case reported herein, the hydrosurgery system proved beneficial for capsulectomy.

Wound bed preparation is necessary for proper wound healing, and debridement is an important approach for achieving healing. Versajet II (Smith & Nephew, Fort Worth, TX) is a hydrosurgery system that uses a high-pressure jet of sterile normal saline and is frequently used for the treatment of acute and chronic wounds and burns for easy and precise debridement.¹ Capsule formation due to fluid collection is difficult to treat and easily persists over a long period of time until complete recovery. The authors encountered a patient with fluid collection who was treated using hydrosurgery with subsequent capsule removal.

A 75-year-old man underwent wide- excision surgery for soft tissue sarcoma in the left scapular region by orthopedic surgeons at Keio Gijuku Daigaku (Shinanomachi Campus, Shinjuku-ku, Tokyo, Japan). Thereafter, plastic surgeons reconstructed the defect using a local flap to prevent exposure of the scapula bone edge (Figure 1). Although this patient had a suction drain removed on postsurgical day 11, fluid collection remained. Thus, he was observed in an outpatient clinic and drained of fluid as required. 

At the 2-month follow-up visit, a fistula measuring 15 cm x 10 cm had developed due to projection of the scapula bone. There were no signs of infection. Therefore, a pedicled latissimus dorsi (LD) muscle flap was harvested (15 cm x 6 cm) to close the wound and fill dead space. The surgery was initiated after marking the subcutaneous pocket made by fluid collection and designing the LD flap (Figure 2A). The flap was raised, and it was observed that a capsular film had formed, releasing the pocket from the caudal side (Figure 2B). The capsule was debrided using the hydrosurgery system. The tissue was removed under the subcapsular layer with little bleeding. No capsule remained on the distant cranial side (Figure 2C). Thereafter, the dead space was filled with the LD flap. Suction drains were inserted subcutaneously in the right scapular, right back, and right lumbar regions to prevent postoperative fluid collection (Figure 3). 

The drains in the right back and right scapular regions, where fluid collection occurred preoperatively, were removed on postsurgical days 6 and 10, respectively. However, the drain in the right lumbar region, where the flap was harvested from, was retained until postsurgical day 16 because the effusion did not decrease (Figure 4). The lumbar drain was removed, while the effusion persisted, due to the risk of infection increasing from leaving the suction drain in for more than 2 weeks. The regions debrided with the hydrosurgery system (right back and right scapular) adhered well to the subcutaneous tissue where fluid collection occurred prior to surgery (even though incision and drainage were performed following discharge due to persistent fluid collection); therefore, recurrence of fluid collection and capsule was not observed. 

Following hospital discharge, the patient was followed-up monthly. No adverse events occurred.

First, sufficient angiogenesis is necessary to achieve appropriate wound healing.² However, capsulized tissue formation due to fluid collection results in synovial metaplasia and fibrosis, preventing effective blood flow.³ Fluid collection is the most common complication with LD flaps due to disruption of the lymphatic and vascular channels, dead space, and mediators of infection.^4,5 For reducing seroma, it is strongly recommended to use a suction drain and wait until the output is below 20 cc to 50 cc over a 24-hour period to remove the drain,⁶ although it is impossible to completely prevent fluid collection. Capsular tissues made by such fluid collection interrupt wound healing. Therefore, it is important to create the proper environment by debriding and refreshing the wound. 

The hydrosurgery system used in this case report makes precise debridement possible. Indeed, the minimal excision depth of the hydrosurgery system is 40 µm, whereas conventional debridement using a surgical knife, for example, extends deeper into normal tissue.⁷ Excessive excision depth may increase exudation after treatment and cause fluid collection recurrence. In addition, this device is cost effective compared with conventional instruments for precise debridement, especially for soft tissues such as the capsule tissues in the present case.⁸ Hydrosurgery also is used for delicate regions, such as the face and fingertips, and favorable results have been reported.⁹ Precise debridement was possible in the present case without the presence of remaining capsular tissue and subtle bleeding.

The right back and right scapular regions, which were debrided by the hydrosurgery system, had their suction drains removed early. As stated above, precise debridement and proper wound bed preparation may lead to early drain removal and prevent the recurrence of fluid collection. 

This report is limited because it is about a single good result achieved by hydrosurgery. However, appropriate wound healing is necessary for better outcomes, and hydrosurgery, which is beneficial for capsule debridement, may facilitate the achievement of better outcomes.

Hydrosurgery is widely used for various cases with a central focus on burns and abscesses and is able to debride precisely.¹⁰ Nevertheless, a literature review revealed no report on capsulectomy by hydrosurgery. Clinicians should be aware that debriding a capsule after fistula formation and preparing the wound for closure by hydrosurgery may show favorable results, as in the case presented herein. 

Affiliation: Department of Plastic and Reconstructive Surgery, Keio Gijuku Daigaku, Shinanomachi Campus, Shinjuku-ku, Tokyo, Japan

Correspondence: Yushi Suzuki, MD, Keio University School of Medicine, Department of Plastic and Reconstructive Surgery, Shinanomachi 35, Shinjuku-ku, Tokyo, Japan 160-8582;  yushisuzuki-kei@umin.ac.jp

Disclosure: The authors disclose no financial or other conflicts of interest.