UROGENITAL TRAUMA

Experience with Wound VAC and Delayed Primary Closure of Contaminated Soft Tissue Injuries in Iraq
Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C
Department of Surgery, Wilford Hall Medical Center, Lackland Air Force Base Texas, USA
J Trauma. 2006; 61: 1207-11

• Background: Wartime missile injuries are frequently high-energy wounds that devitalize and contaminate tissue, with high risk for infection and wound complications. Debridement, irrigation, and closure by secondary intention are fundamental principles for the management of these injuries. However, closure by secondary intention was impractical in Iraqi patients. Therefore, wounds were closed definitively before discharge in all Iraqi patients treated for such injures at our hospital. A novel wound management protocol was developed to facilitate this practice, and patient outcomes were tracked. This article describes that protocol and discusses the outcomes in a series of 88 wounds managed with it.
• Methods: High-energy injuries were treated with rapid aggressive debridement and pulsatile lavage, then covered with negative pressure (vacuum-assisted closure [VAC]) dressings. Patients underwent serial operative irrigation and debridement until wounds appeared clean to gross inspection, at which time they were closed primarily. Patient treatment and outcome data were recorded in a prospectively updated database.
• Results: Treatment and outcomes data from September 2004 through May 2005 were analyzed retrospectively. There were 88 high-energy soft tissue wounds identified in 77 patients. Surprisingly, for this cohort of patients the wound infection rate was 0% and the overall wound complication rate was 0%.
• Conclusion: This series of 88 cases is the first report of the use of a negative pressure dressing (wound VAC) as part of the definitive management of high-energy soft tissue wounds in a deployed wartime environment. Our experience with these patients suggests that conventional wound management doctrine may be improved with the wound VAC, resulting in earlier more reliable primary closure of wartime injuries.
  
  
• Editorial Comment
  The vacuum assisted closure system is an effective, simple, and under-utilized method to help repair and close wounds. In the Iraq War, many of the injuries have devastating soft tissue defects that are ideal for negative pressure wound therapy. Numerous urologic injuries have also been seen during the Iraq conflict. Such complex urologic wounds on the penis, perineum, and scrotum are also ideal for such therapy after initial debridement.. The first report of negative pressure wound therapy (NPWT) was by Fleischmann et al., Unfallchirg. 1993; 96: 488-92. It has been FDA approved since 1995. To perform NPWT, place a sterile foam dressing into wound defect, followed by a non-collapsible fenestrated tubing exits foam parallel to skin, connected to vacuum pump. The open wound is then converted into controlled closed wound (adhesive transparent film dressing placed on top of foam). Machine settings are typically 125 mmHg of negative pressure continuously or cyclically (5 min on, 2 min off). Dressing changes are made every 48 hours or 3 x/ week.
  NPWT helps wounds to close and heal by the following mechanisms: removal of excessive interstitial edema, decompresses small vessels and restores local blood flow; removes chronic wound fluids rich in matrix metalloproteases (inhibit wound healing); mechanical deformation of cells, with foam collapse, traction forces perturb the cytosketon and stimulate fibroblast, endothelial cell and vascular smooth muscle cell proliferation. Contraindications to NPWT are: malignancy in the wound, tissue necrosis (large amounts) with scar (debride before starting VAC), untreated osteomyelitis, insufficient vascularity to sustain any wound healing, untreated malnutrition.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA