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How I do it

Negative pressure wound therapy with off-the-shelf components

Trung D. Bui, M.D.a,b,*, Sergio Huerta, M.D.a,b, Ian L. Gordon, M.D., Ph.D.a,b

aVA Long Beach Healthcare System, Department of Vascular Surgery, Long Beach, CA, USAbDepartment of Vascular and Endovascular Surgery, UCI Medical Center, 101 The City Dr., Bldg. 53, Rte. 81, Orange, CA 92868, USA

Manuscript received July 22, 2005; revised manuscript January 16, 2006

bstract

ackground: The KCI Wound VAC system (Kinetic Concepts, Inc, San Antonio, TX) for providing negative-pressure therapy for woundss expensive and may not be available for patients without insurance. We have examined the feasibility of using off-the-shelf componentso provide comparable negative pressure therapy at less cost.

ethods: Adhesive iodine-impregnated drape, a flat Jackson-Pratt drain (Cardinal Health, McGaw Park, IL), and foam prep spongestapled together are used to assemble a dressing connected to wall suction (negative 75–100 mm Hg) to create negative pressure woundherapy that is relatively inexpensive (�$60 component cost).esults: We have used this system in more than 40 cases with results that seem comparable to the commercial system and have not seenleeding or other complications.onclusion: Off-the-shelf components can be safely employed to provide effective negative pressure therapy for wounds and skin grafts.2006 Excerpta Medica Inc. All rights reserved.

The American Journal of Surgery 192 (2006) 235–237

eywords: Negative pressure therapy; Wound, Skin graft; Vacuum assisted closure; Off-the-shelf system

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he application of negative pressure to promote woundealing first was described in the Russian medical liter-ture for patients with infected breast wounds. Theseriginal reports described the topical application of auction-cup–type apparatus to the wound surface to cre-te negative pressures of 80 mm Hg [1,2]. Subsequenteports have described the successful management ofnterocutaneous fistulae and open abdominal wounds us-ng flat drains delivering negative pressure under com-liant plastic films [3–5]. In these early reports surgicalauze was used to create an interface between the woundurface and the vacuum source.

Kinetic Concepts, Inc. (KCI; San Antonio, TX) mar-ets a modular negative pressure system (Wound VAC)hat is based on the system developed by Argenta and

orykwas [6] and Morykwas et al [7] by using foamponges connected to suction tubing and a vacuum pumpontaining a small canister. Other commercial vendorsarket similar systems. The KCI system has been used

ery successfully to treat a large variety of wound prob-ems such as dehisced incisions, leg ulcers, and skin

* Corresponding author. Tel.: �1-714-281-2012; fax: �1-714-456-7207.

tE-mail address: buitd@uci.edu

002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reservoi:10.1016/j.amjsurg.2006.01.013

rafts, and has been adopted very rapidly into surgicalractice across many disciplines [8 –13]. The advantagesf negative pressure therapy appear to include betterontrol of wound secretions, reduction of wound edema,romotion of granulation, improved patient comfort, and,ased on some clinical trial data, more rapid healing8 –13]. The foam sponges used in the commercial systemrovide a good, possibly optimal, interface between theound and the vacuum source because of the even dis-

ribution of suction exerted by the porous foams and theirbility to capture secretions.

We have been using the KCI Wound VAC system withood results, but because of financial considerations weave tried to develop a method of providing patients withimilar negative-pressure therapy without the significantosts of purchasing or renting the KCI system, which canost more than $100 per day. We have developed aethod of creating negative pressure in wounds by usingidely available off-the-shelf components that is easy to

onstruct and apply and, based on our experience in morehan 40 cases, appears to provide nearly equivalent ef-ects on wound healing. We use this system wheneveregative-pressure therapy is indicated and the KCI sys-

em is not available.

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236 T.D. Bui et al. / The American Journal of Surgery 192 (2006) 235–237

echniques

As shown in Fig. 1, the construction of our off-the-shelfystem requires materials commonly used in the operatingoom: (1) a surgical stapler (model PXW35; Ethicon, Cin-innati, OH); (2) foam sponges used for dressings or forurgical preparation (model 4463; Cardinal Health, McGawark, IL); (3) a 10-mm Jackson Pratt (JP) drain (modelU130-1311; Cardinal Health); (4) Ioban adhesive filmnd Ioban iodine-impregnated transparent surgical drapemodel 6651EZ; 3M, St. Paul, MN), and (5) a wall suctiononnector (model P361; Cardinal Health) for the JP drain todapt into standard suction tubing. The system, once con-

ig. 2. (A) A complex foot wound that developed in a diabetic patient withrterial occlusive disease. The patient previously underwent revasculariza-ion, and the wound has just been debrided sharply. (B) Acticoat has beenpplied onto the wound. (C) The sponge raft has been assembled bytapling 3 individual foam sponges together. (D) The sponge raft has beenlaced over the wound and trimmed to accommodate the wound margins

ig. 1. Elements of an off-the-shelf negative-pressure dressing. Shownlockwise, starting at the top left corner, are the stapler, sponge raft,cticoat, JP drain, and tubing connector. The Ioban adhesive film isnderneath these items.

aust before covering with Ioban adhesive film.

tructed, routinely is connected to a 1-L suction canister ando standard wall suction at 75 to 100 mm Hg negativeressure. We use the lower pressure for skin grafts andigher pressures when wound drainage is indicated.

In general, the wound to be treated is debrided to removeecrotic or infected tissue before the application of nega-ive-pressure dressings (Fig. 2A). To ensure an adequateeal with the overlying adhesive film, the surrounding skinust be as dry as possible. In many cases, particularly with

plit-thickness skin grafts, we place a porous silver meshetween the wound and the sponges (Fig. 2B). We havesed either multilayer 7-day release silver mesh (7-daycticoat; Smith & Nephew, Largo, FL) or several layers of

he silver mesh from the standard 1-layer Acticoat (Smith &ephew). Such silver mesh barriers provide a sustained

ntimicrobial environment and seem particularly apt for useith negative-pressure dressings over skin grafts [14]. Weave used a variety of other topical products between theponge and the wound tissue including antibiotic ointments,apain preparations, and growth factor gel, all of whicheem to be compatible with negative-pressure therapy [15].

Foam sponges are stapled together to form a raft largerhan the wound to be treated using 3 to 4 staples to connectach sponge (Fig. 2C). The assembled foam then is cut toatch the wound and secured with 1 or 2 staples to the

djacent skin (Fig. 2D). A layer of Ioban adhesive then israpped tightly to seal the entire wound. The Ioban adhe-

ive is cut in the center with a scalpel or scissors to createn approximately 1-cm diameter defect. The JP drain, withost of the perforated portion removed, is placed over the

efect and secured with another layer of Ioban adhesiveFig. 3A). Additional layers of Ioban adhesive are wrappedround the JP to seal the wound completely. A wall suctiononnector then is used to establish continuity between the JP

ig. 3. (A) After sealing the sponge raft to the foot with a layer of Iobandhesive film, a 1-cm diameter defect is made directly in the adhesive filmver the middle of the raft. The JP drain, cut to a short segment, is placedver the perforation and sealed with a second layer of adhesive film.acuum has not yet been applied. (B) The tubing now is connected to aacuum and the characteristic collapse of the sponge raft, indicating ef-ective delivery of negative pressure, is present.

nd wall suction. A negative pressure of 75 mm Hg induces

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237T.D. Bui et al. / The American Journal of Surgery 192 (2006) 235–237

he characteristic collapse of foam sponges seen in otherystems (Fig. 3B). Skin graft dressings usually are left inlace for 5 days. Our practice with open wounds is toeplace the dressing every 2 or 3 days.

omments

We have used the off-the-shelf system for managementf leg ulcers, diabetic foot infections, dehisced extremitynd abdominal incisions, and split-thickness skin grafts in0 patients in the past 2 years. In general, we have seen veryimilar local wound responses as observed with the KCI

ound VAC. We have found the off-the-shelf system to bearticularly good for skin graft dressings, and we now rou-inely use either the KCI or the off-the-shelf system withouteeing any difference in results.

Based on our hospital purchase expenses, the overall costequired to assemble 1 off-the-shelf system using 1 stapler,box of foam sponges, 1 large sheet of Ioban, 1 JP drain,

nd 1 connector is less than $60. This estimate does not takento account charges for using the wall suction apparatus,hich also is low.We believe that only a minor difference in distribution of

acuum suction to the wound results from substituting mul-iple sponges stapled together versus a single sponge. Ourethods allow the foam layer to be tailored easily to match

he wound dimensions; in deep wounds the sponges can beiled in layers. The application of the vacuum should besed to test the system in the operating room or at bedside,nd rapid compression of the sponge raft when vacuum ispplied reliably indicates that no significant leak is present.

Although we have not observed any problems with hem-rrhage with this method (eg, discontinuing therapy becausef bleeding), there is some concern that large wounds orhose oozing at the time of dressing application could bleedxcessively into the suction canister, which unlike commer-ial systems does not have a volume cut-off level. Becausef this limitation, we urge caution in using this method forediatric wounds in which drainage volumes should be mon-tored carefully, and for very large wounds or those likely toleed excessively.

Other limitations of the off-the-shelf system include thenability to modify the pressure cycle (eg, intermittent suc-ion) and to treat patients on an outpatient basis because ourevice uses simple wall suction for negative pressure. De-pite these limitations, our system is invaluable for patientsho would benefit greatly from negative-pressure therapyut who are unable to obtain access to commercial systems

s a result of funding, cost considerations, or unavailability.

A recent clinical trial indicated that negative-pressureherapy is more cost effective than traditional saline-soakedauze dressings [16]. Unfortunately, in the current healthare environment, commercial technology is not alwaysvailable as a result of cost or insurance authorization is-ues. The components required in this off-the-shelf systemre available in most community hospitals and are easy topply to manage inpatient wound problems, and based onur experiences it provides results similar to more complexommercial systems.

eferences

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[2] Davydov YA, Malafeeva EV, Smirnov AP, et al. Vacuum therapy in thetreatment of purulent lactation mastitis. Vestn Khir 1986;137:66–70.

[3] Chariker ME, Jeter KF, Tintle TE, et al. Effective management ofincisional and cutaneous fistula with closed suction wound drainage.Contemp Surg 1989;34:59–63.

[4] Smith LA, Barker DE, Chase CW. Vacuum pack technique of tem-porary abdominal closure: a four year experience. Am Surg 1997;63:1102–7.

[5] Brock B, Barker DE, Burns RP. Temporary closure of open abdom-inal wounds: the vacuum pack. Am Surg 1995;61:30–5.

[6] Argenta LC, Morykwas MJ. Vacuum-assisted wound closure: a newmethod for wound control and treatment: clinical experience. AnnPlast Surg 1997;38:563–76.

[7] Morykwas MJ, Argenta LC, Shelton-Brown EL, et al. Vacuum-assisted closure: a new method for wound control and treatment:animal studies and basic foundation. Ann Plast Surg 1997;38:553–62.

[8] Garner GB, Ware DN, Cocanour CS, et al. Vacuum-assisted woundclosure provides early fascial reapproximation in trauma patients withopen abdomen. Am J Surg 2001;182:630–8.

[9] Kovacs LH, Kloepel M, Papadopoulos NA, et al. Necrotizing fasci-itis. Ann Plast Surg 2001;47:680–1.

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12] Miller PR, Thompson JT, Faler BJ, et al. Late fascial closure in lieuof ventral hernia: the next step in open abdomen management.J Trauma 2002;53:843–9.

13] Tang ATM, Ohri SK, Haw MP. Novel application of vacuum assistedclosure to the treatment of sternotomy wound infection. Eur J Car-diothorac Surg 2000;17:482–4.

14] Dunn K, Edwards-Jones V. The role of Acticoat with nanocrystallinesilver in the management of burns. Burns 2004;30(Suppl 1):S1–9.

15] Carson SN, Overall K, Lee-Jahshan S, et al. Vacuum-assisted closureused for healing chronic wounds and skin grafts in the lower extrem-ities. Ostomy Wound Manage 2004;50:52–8.

16] Philbeck TE, Whittington KT, Millsap MH, et al. The clinical andcost effectiveness of externally applied negative pressure woundtherapy in the treatment of wounds in home healthcare Medicare

patients. Ostomy Wound Manage 1999;45:41–50.