Modern Surgical Techniques For Wound Debridement

Introduction

Wound debridement is the process of removing necrotic tissue from the skin. It is vital for proper wound care, yet queries about method, frequency, and extent linger are unresolved. The wounds are affected by bacteria and debris; the debris produces toxins and turns the wound into a thin yellow layer over the other tissue.¹ Surgeons perform surgical debridement, which is performed in the operating room. Still, other types of wound debridement that do not require much care are done by nurses, family members, or patients themselves.²

Purpose of debridement: It helps to reduce the bacterial burden within the wound, controls inflammation, and encourages the formation of granulation tissue.

Historically, various methods for wound debridement have been employed in medical settings, including autolytic, enzymatic, bio-debridement, mechanical, conservative sharp, and surgical techniques.³

Surgical debridement:

• It is the excision of necrotic material and includes viable tissue margins. The procedure is carried out under anaesthesia.¹
• Surgical debridement is mostly performed on wounds such as diabetic foot ulcers and the tissues that change in shade to brown or grey and become stringy (due to high moisture levels).¹

In this article we will read and learn about some of the modern surgical methods used in wound debridement.

1. Sharp debridement: it is a surgical method of wound debridement involving the use of sharp instruments such as scalpels or scissors to remove necrotic or non-viable tissue precisely and rapidly from a wound. This technique is particularly effective for wounds with thick, adherent necrotic tissue. Sharp debridement is typically performed by trained healthcare professionals in a clinical setting and is considered an efficient approach to wound care.⁴
2. Laser debridement: This method uses laser technology to remove the necrotic or unhealthy tissue precisely and selectively from wounds or lesions. The laser is focused to target a specific area without causing damage to surrounding healthy tissue. Laser debridement is often used in the treatment of chronic wounds, burns, and certain dermatological conditions, offering a minimally invasive and efficient treatment.⁵
3. Ultrasonic debridement: It operates on the principle that atomised saline serves as a conductor for ultrasound waves to effectively reach the treatment site.⁶ Substances like fibrin, tissue exudates, and bacteria are removed in the process. The combined action of targeted ultrasound and debridement is aimed at promoting the overall healing process in chronic wounds, which can be particularly challenging to treat.⁶
4. Hydro surgery: The technique is based on the principle of the venturi effect. Saline solution is inserted into the skin, creating a vacuum. The suction permits the removal of the targeted tissue site.⁶
5. Enzymatic debridement: This technique involves the application of specialised enzymatic agents to necrotic or devitalised tissue in order to break down and facilitate the removal of this non-viable tissue from a wound. These enzymes work by selectively targeting and digesting the dead tissue, leaving healthy tissues unharmed. Enzymatic debridement is often used for wounds with moderate to heavy necrotic tissue burden, and it is particularly suitable for patients who cannot tolerate more aggressive debridement methods like sharp debridement. It is considered a more gentle and less invasive approach to wound care.⁴
6. Negative pressure wound therapy (NPWT): It is an advanced wound care technique that utilises a vacuum-assisted device to promote wound healing. NPWT involves placing a special dressing over the wound and applying controlled negative pressure through a connected device. The negative pressure helps to remove excess fluid, debris, and infectious materials from the wound, thus facilitating debridement. This technique also promotes blood flow and the formation of healthy tissue, contributing to the overall healing process. NPWT is generally used for a variety of wound types, including chronic wounds, surgical wounds, and traumatic injuries.⁷
7. Biofilm disruption: It is a specialised approach to wound care that targets the removal of bacteria biofilms present in chronic wounds. Biofilms are communities of bacteria encased in a protective matrix, making them highly resistant to traditional antibiotic treatment. This debridement method employs techniques, such as mechanical or enzymatic interventions, specifically designed to disrupt and break down the biofilm structure; performing bacteria disruption debridement can help promote wound healing and reduce the risk of chronic wound infections.⁸
8. Coblation technology (CT) debridement: The technique is based on local induction of a focused plasma field chemically deleting undesired tissues. This technique is an upgrade of electrosurgical debridement.⁹.It is a cutting-edge technology utilising a stable, low-temperature plasma field for precise tissue removal. It excels in treating diseased cartilage, ensuring accurate and precise removal of damaged tissue while minimising harm to nearby healthy cartilage.^10.Coblation chondroplasty proves to be more cost-effective and is generally used for knee articular cartilage lesions.¹⁰

It uses bipolar radio frequency to energise molecules in a conductive solution around an active electrode, forming a precise plasma field. The innovation enables controlled and minimally invasive tissue removal.⁶

When not to debride?

• Assessment is crucial before deciding to debride a wound, especially when there are situations where leaving necrotic tissue in place is risky.¹¹
• In cases of underlying vascular disease with associated gangrene, it is essential to wait for a demarcation line before operation.¹¹
• Early intervention can lead to infected gangrene spreading and possibly require higher amputation.¹¹
• If the patient is terminally ill, retaining necrotic caps may be beneficial, especially if they are not causing discomfort and there is no bad smell or excessive discharge. Although the wound would not heal with necrotic tissue in place, potential benefits must be weighed against increased risk of intervention and potential patient disruption if the caps are removed.¹¹
• When a dry cap coincides with cellulitis, exudate, or odour, antimicrobial therapy must be considered to manage symptoms and relieve the patient's physical and psychological distress.¹¹
• Caution is necessary if a wound displays clinical signs of infection.

Summary

Wound debridement is the removal of necrotic tissue. Debridement aims to reduce bacterial burden, manage inflammation, and stimulate granulation tissue. Other techniques that were or are used for wound debridement are autolytic, enzymatic, bio-debridement, mechanical, conservative sharp, and surgical techniques. Sharp Debridement: surgical removal using scalpels or scissors for thick necrotic tissue. Laser Debridement: precise laser technology for minimally invasive tissue removal. Ultrasonic Debridement: atomized saline aids ultrasound waves for effective wound cleaning. Hydrosurgery: creates a vacuum with saline for targeted tissue removal. Enzymatic Debridement: specialised enzymes gently break down necrotic tissue, sparing healthy tissue. NPWT: controlled negative pressure removes debris, enhances blood flow, and aids tissue formation. Biofilm Disruption: targets and breaks down bacterial biofilms in chronic wounds. Coblation Technology (CT) Debridement: uses low-temperature plasma for precise tissue removal, suitable for knee cartilage lesions.

Assessment is key before surgery, especially when necrotic tissue poses risks. Wait for a demarcation line in vascular disease with gangrene. Early action can cause infected gangrene and necessitate amputation. Consider the pros and cons of keeping necrotic tissue caps for terminally ill patients. Exercise caution with infected wound signs.

One should visit a healthcare professional if in an emergency.