Surgical Debridement With a Scalpel

In this video, John C Lantis II, MD, FACS, Mount Sinai Morningside and Mount Sinai West, New York, NY, demonstrates how to perform surgical debridement with a scalpel. Dr. Lantis also addresses when it is and is not appropriate to surgically debride, and how clinicians can control bleeding they may encounter.

Transcript:

Hello, I'm John Lantis, vascular surgeon, and today I'd like to spend a little bit of time speaking to you about the benefits of debridement and some fundamentals of the technique. Very simple office-based debridement for the outpatient wound. The goals of debridement are to take away the skin edges that would be hyperkeratotic, which would be around the edges. Those cells are actually cells that usually don't even know how to migrate across the wound bed and need to be removed. But one also doesn't want to forget the base of the wound, where at the base of the wound you would have increased bacterial burden and cells, if they're present, that are very senescent or quiescent, and that they're not able to turn over. So there are various ways of debriding and methods, but we're going to be talking about sharp debridement today, specifically. Sharp debridement you want to have a rounded blade; using an 11 blade, which is the pointed blade, is not useful in most cases.

So this is a 10 blade; a 15 blade--which looks like the junior cousin of this and is just a smaller version, fundamentally--can be useful as well, although it has less of a cutting surface. A 10 blade is also better for very difficult callous, but harder for small wounds. You also always want to be a two-handed debrider or two-handed surgeon. You want to have something in your other hand that allows for counter force. Of course, in some settings you might want to use scissors as well, but first we're going to teach about using the blade. What you're going to want to do is come in at about a 45-degree angle on the edges, and I always tell my residents that cells are much more happy to run down a beach than to jump off a cliff. So you want to get that circumferential 45-degree beveled angle out to healthy bleeding tissue in most cases, which is also a requirement for documentation in most environments.

So you keep your hand at an angle in which, I know this might be hard to see on camera, but you keep your hand at an angle in which you can bevel those edges at that 45-degree angle. Once you have the edges taken back, then you're going to work at the base of that wound. The base of that wound you may want to almost scrape like this to get healthier. Sometimes you're going to get in and underneath the tissue in that wound as you pick it up and move it like this. And sometimes if they have a lot of fibrinous base, one of the things you can do is to take the back of your forcep, which is less likely to be very sharp and damaging, and really get the fiber slough off down there.

To get that done you have gauze in your other hand, you can wipe that clean on the other side and use it that way or you can also use the back of your scalpel--especially the 15 blade, which is smaller than this, lends itself to this very well. You use the back of the scalpel and get that clean. You don't want to forget, though, the edges or the base of the wound to get the maximal results. After that, you can worry about topical hemostasis. Usually a little pressure is good enough. At times you may want to use silver nitrate, somewhat sparingly--remember it's bacteriostatic, but it will be helpful to have on hand. Our usual setup for debridement will include having topical lidocaine applied and left in place for approximately 10 minutes prior to debridement if the patient has pain; having our sharp instruments available to us; having a disposable forcep in the outpatient setting because that's easier to deal with; and then having appropriate secondary dressing on hand or an appropriate assistant available to help you at the end of the procedure.