Apart from the extent and depth of burns, inflammatory reactions and infections (caused by impurities, cell detritus, bacterial degradation etc.) impair the healing of burn wounds. Bacterial colonization and invasion significantly influence wound healing (epithelialisation and contraction of the wound) . Early debridement and depth-specific early coverage are currently the standard in the surgical treatment of burns [2,3,8,10]. Basic prerequisites are exact determination of the depth and accurate debridement. Particularly in cases of large burn wounds it is essential to preserve and protect vital tissue. In cases of wide, generous removal of tissue by the use of the Dermatom, Guilon or Humbey knife, one frequently removes more than the actual burned tissue and unnecessarily damages vital tissue. On the other hand, one may remove too little necrotic tissue. The depth of the burn may be difficult to difficult to assess so that the surgeon waits too long, causing valuable time to lapse during which he may well have performed surgical repair. Accurate ablation of the damaged layers of skin and identification of petechial bleeding help to assess the vitality of tissue. This permits exact determination of depth (whether the subpapillary, cutaneous or subdermal plexus are preserved) [9,16] and depth-specific coverage.
Versajet® is a hydrosurgical system employing a jet of water by which tissue is simultaneously cut, ablated, and suctioned. The wound is rinsed without significant aerosolisation. This system has been approved by the US Food and Drug Administration (FDA) for debridement of wounds and soft tissue as well as CE-certified for ablation of tissue and other substances in various surgical procedures including wound debridement . The system is based on the Venturi principle: a thin high-velocity jet of water consisting of sterile saline is discharged from a 0.12-mm nozzle into a suction tube (see Table 1). The consistency of the working tip and the velocity of the water jet create a vacuum below the incision window. This aspirates, cuts and suctions the tissue. As the handpiece is held parallel to the wound the high-pressure water jet acts as a scalpel. When the working tip is tilted slightly the scalpel effect of the water jet is reduced while the rinsing and suction effect is enhanced. Furthermore, the quantity of ablated tissue is determined by the pressure settings at the console (1-10), the pressure exerted by the surgeon, and the speed at which the handpiece is moved on tissue. The console is operated by a foot pedal. Hydrosurgical systems have been in use for a large variety of indications . However, they have not entered burn surgery thus far. Further development of the concept led to a more modern system, namely the Versajet® system, which works precisely and simply. A number of handpieces are currently available for various purposes. They differ in terms of the size of the surgical window and the angle of the working tip: 8 mm surgical window, 45° angle, 14 mm surgical window, 15° or 45° angle of the working tip. Furthermore, the different holders are also available in a Versajet plus® variation which enables the surgeon to forcefully ablate tough tissue.The basic principles underlying this concept were derived from histological investigations. The exact layer-wise removal of tissue components achieved by this procedure is of the same quality as that achieved by laser ablation. The Versajet system® was also successfully used for the treatment and the removal of dirt-tattoos/pigment deposits.
|1||90 ml/min||103 bar 426 km/h|
|3||125 ml/min||265 bar 591 km/h|
|7||188 ml/min||587 bar 885 km/h|
|10||230 ml/min||827 bar 1078 km/h|
2. Case 1
Figures 1 to 5 show a 6-year old boy with partial to full thickness scalds in the neck. Large portions of the chest were also affected. Necrosectomy with Versajet® (at levels 5–7) and subsequent coverage with unmeshed split-thickness skin graft were performed on the 4th day after the accident. Fat gauze was placed on the grafts. A collar was provided to protect the grafts and immobilize the neck postoperatively. On the 6th postoperative day the split-thickness skin grafts had healed in a stable manner. Bacterial investigations performed before and after the treatment showed no microbial growth. The functional outcome after six months was favourable.
3. Case 2
Fig. 6 to 10 show a 45-year-old man who developed partial to full thickness-burns in both hands and partial thickness burns in the forearm and face during a car accident. Necrosectomy with Versajet® (at levels 3–5) and split-thickness skin grafting on the dorsum of the left hand were performed on the 2nd day after the accident. The hand covered with a split-thickness skin graft was covered with fat gauze and immobilized with a splint for 6 days. The remaining burned areas were superficially cleaned with Versajet® (at level 3) and treated with Acticoat because the smears showed colonization of germs in the wounds. On the 6th postoperative day the split-thickness skin grafts had healed in a stable manner. The smears showed no microbial growth. Function and aesthetics were satisfactory after six months.
4. Case 3
Fig. 11 to 12 show a 40-year-old man who partial thickness burns in the face covered with pigment deposits after an explosion. Dirt tattoos has been removed by using the hydro surgery system at level 3 with a very superficial removal of the pigment deposits. Uneventful healing shows a clean skin after 2 weeks without scarring.
The experience shows that in cases of full thickness burns a necrosectomy with the Dermatom, Humbey knife or the scalpel could be performed rapidly and efficiently. In these cases Versajet® was of use only in marginal zones or to provide the wound with the necessary finishing touches. Tissue damaged in a leathered fashion could not be ablated rapidly or satisfactorily even by the use of Versajet plus®. In contrast, the advantages of Versajet in the treatment of partial thickness burn wounds are worthy of mention. In particular, burns in complex, inaccessible areas are an indication for the use of this hydrosurgical system. In the region of the face (the lips, eyelids, etc.) debridements can be performed with a degree of precision that is hardly achievable by the use of conventional methods. Furthermore, necrosectomy in the region of the hand (fingers, interdigital spaces, etc.) can be significantly improved by the use of Versajet®. In burn surgery convex surfaces could be ablated uniformly and concavities curetted with precision. Pigment deposits could be completely removed. Histological investigations prove and confirm the precision of ablation by the use of Versajet®.
Fig. 13: This technique permits ablation of clearly defined anatomical structures. Removal of the most superficial layers of skin, dermal papillae/papillary dermis (Fig. 13a). Layer of the superficial reticular dermis, removal of the epidermis, the papillary dermis, and superficial portions of the reticular dermis (Fig. 13b). Layer of the mid reticular dermis (Fig. 13c).
In cases of large partial thickness burns this method was very helpful to achieve effective wound debridement. At level 2-3, impurities, coatings and cell detritus could be removed in a simple, rapid and gentle manner and microbial growth could thus be reduced. Smears and biopsies taken before and after the treatment showed marked reduction of microbial growth in all cases. In superficial wounds that could be treated with Versajet® we observed more rapid re-epithelialisation compared to conservative treatment on the side with the same depth of burns treated with fat gauze. In no case did we encounter side effects or undesired events. Steps, unevenness or ridges in tissue were caused by lack of practice, but could be corrected during the procedure. Postoperative wound dressing was performed according to the general guidelines of burn treatment.
As rapid debridement and immediate deep coverage should be performed for the reasons mentioned at the beginning of this report as well as to avoid the risk of hypertrophic scar formation , Versajet® fulfils standards of precision, rapid intervention and simple handling. The special domain of Versajet® is partial thickness burns, particularly in poorly accessible anatomical regions [4,13]. These regions can be treated and debrided more effectively by the use of hydrosurgical systems than with conventional methods. By means of layer-wise ablation the surgeon is able to identify healthy tissue immediately and protect it in the best possible manner. Intraoperative diagnosis of the depth of burns is also achieved by this procedure. Owing to these advantages the Versajet® system has become a standard procedure in burn surgery.
Bojrab MJ: A Handbook on Veterinary Wound Management. Ashland, OH: KenVet Professional Veterinary Company, 1994
Breie Z, Zdrovic F: Lessons learned from 2409 burn patients operated by early excision. Scand J Plast Surg 1979; 13: 107–118
Burke JF, Quimby WC, Bondoc CC: Primary excision and prompt grafting as routine therapy for the treatment of thermal burns in children. Surg Clin N Am 1976; 56: 477–494
Cubison TC, Pape SA, Jeffery SL: Dermal preservation using the Versajet ® hydrosurgery system for debridement of paediatric burns. Burns 2006; 32: 714–720
Eldad A, Weinberg A, Breiterman S, Chaouat M, Palanker D, Ben-Bassat H: Early nonsurgical removal of chemically injured tissue enhances wound healing in partial thickness burns. Burns 1998; 24: 166–172
Falabella AF: Debridement and wound bed preparation. Dermatologic Therapy 2006; 19: 317–325
Granick MS, Possnett JW, Jackoby M, Noruthum S, Ganchi P, Daliashvili R: Efficacy and cost-effectiveness of the high powered parallel water jet for wound debridement. Poster, EWMA, Stuttgart, 2005
Herndon DN, Gore D, Cole M et al.: Determinants of mortality in pediatric patients with greater than 70% full thickness total body surface area thermal injury treated by early total excision and grafting. J Trauma 1987; 27: 208–212
Jackson DM: The diagnosis of the depth of burning. Br J Surg 1953; 40: 588–596
Janzekovic Z: A new concept in the early excision and immediate grafting of burns. J Trauma 1970; 10: 1103–1108
Kamolz LP, Andel H, Haslik W, Winter W, Meissl G, Frey M: Use of subatmospheric pressure therapy to prevent burn wound progression in human: first experiences. Burns 2004; 30: 253–258
McDonald WS, Deitch EA: Hypertrophic skin grafts in burned patients: a prospective analysis of variables. J Trauma 1987; 27: 147–150
Rennekampff H-O, Schaller HE, Wisser D, Tenenhaus M: Debridement of burn wounds with a water jet surgical tool. Burns 2006; 32: 64–69
Shekarriz B, Shekarriz H, Upadhyay J, Wood DP, Bruch HP: Hydro-jet dissection for laparoscopic nephrectomy: a new technique. Urology 1999; 54: 964–967
Sheridan RL, Lydon MM, Petras LM, Schomacker KT, Tompkins RG, Glatter RD, Parrish JA: Laser ablation of burns: initial clinical trial. Surgery 1999; 125: 92–95
Womack BS: Wound management: healing & assessment. Veterinary Technician 2001; 22: 588–594