Vacuum assisted closure technique: a short review
Sankalp Yadav, Gautam Rawal, Mudit Baxi
The Pan African Medical Journal. 2017;28:246. doi:10.11604/pamj.2017.28.246.9606

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Vacuum assisted closure technique: a short review

Cite this: The Pan African Medical Journal. 2017;28:246. doi:10.11604/pamj.2017.28.246.9606

Received: 12/04/2016 - Accepted: 07/06/2017 - Published: 21/11/2017

Key words: Negative pressure, negative pressure wound device, VAC, vacuum therapy, vacuum sealing, wounds, wound closure, wound healing

© Sankalp Yadav et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Available online at: http://www.panafrican-med-journal.com/content/article/28/246/full

Corresponding author: Sankalp Yadav, Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India (drsankalpyadav@gmail.com)


Vacuum assisted closure technique: a short review

Sankalp Yadav1,&, Gautam Rawal2, Mudit Baxi3

 

1Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India, 2Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India, 3Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India

 

 

&Corresponding author
Sankalp Yadav, Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India

 

 

Abstract

The management of difficult to heal wounds has always been a cause of concern for the treating clinicians. There has been a tremendous increase in the number patients presenting with difficult to heal wounds. The conventional techniques have been in use since the long time for the management of these wounds, yet desired results are not achieved always. Thus a newer novel technique which might be useful in the difficult to heal wounds and delivering at par or better results as compared to the conventional techniques is the need of the hour.

 

 

Commentary    Down

A wound is defined as damage or disruption to the normal anatomical structure and function [1]. This can range from a simple break in the epithelial integrity of the skin or it can be deeper, extending into subcutaneous tissue with damage to other structures such as tendons, muscles, vessels, nerves, parenchymal organs and even bone [2]. Wound healing remains a challenging clinical problem and correct, efficient wound management is essential [3]. The primary aim of the practicing clinicians is to achieve a high rate of success in the wound healing. In the countries like India, where the chances of wound infection are high due to multiple issues, the importance of novel techniques of wound care are essential. The scientific community has always looked for a new and more effective wound care techniques, particularly with an emphasis on new therapeutic approaches and the development of technologies for acute and chronic wound management [3]. So far very few remarkable achievements have been reported in the scientific literature. Despite numerous advances, chronic and other difficult to manage wounds continue to be a challenge for the clinicians [4]. The relatively newer techniques like negative pressure wound therapy (NPWT) using the vacuum assisted closure (VAC) are very promising and are also useful in the management of difficult to heal wounds. In this short review, we highlight the importance of the negative pressure wound device (NPWD) in the successful wound healing. We will also discuss the importance of this technique in a developing country like India. The practice of exposing a wound to sub-atmospheric pressure is relatively new and was first described by Fleischmann et al. in the year 1993, who first reported the use of sub-atmospheric pressure for an extended period to promote debridement and healing following the successful use of this technique in 15 patients with open fractures [5]. Their study reported that the treatment method of reducing the pressure inside the wound was very effective. However, the first reports about the use of negative pressure wound device came from Argenta and Morykwas in the year 1997 [4]. The use of controlled levels of negative pressure application has been shown to accelerate debridement and promote healing in various types of wounds [6]. This optimum level of negative pressure appears to be around 125 mmHg below ambient and there is evidence that this is most effective if applied in a cyclical fashion of five minutes on and two minutes off [6]. Earlier studies used more conventional methods such as a wall suction apparatus or surgical vacuum bottles for creating the negative pressure [6]. However, there were multiple problems present in the use of these conventional methods [7]. In the year 1995, a commercial system for promoting vacuum assisted closure (VAC) also known as vacuum therapy, vacuum sealing or topical negative pressure therapy, was introduced into the United States market [6]. This equipment, called the VAC, was designed to overcome some of the problems associated with conventional methods for the creation of negative pressure. The heart of the system is a microprocessor-controlled vacuum unit that is capable of providing controlled levels of continuous or intermittent sub-atmospheric pressure ranging from 25 to 200 mmHg [6]. Later on a number of improvements were made to this basic model of VAC.

 

The mechanism of action

 

The first attempt to explain the physiological basis of the observed good clinical results using NPWT was made by the Morykwas et al. 1997 [8]. Morykwas and colleagues postulated that multiple mechanisms might be responsible for the beneficial results obtained from VAC [6]. They suggested that removal of interstitial fluid decreases localized edema and increases blood flow, which in turn decreases tissue bacterial levels. It has since been proposed that the application of sub-atmospheric pressure produces mechanical deformation or stress within the tissue resulting in protein and matrix molecule synthesis and enhanced angiogenesis [9, 10]. The VAC treatment applies localized negative pressure applied to a special dressing positioned within the wound cavity or over a flap or graft that assists with the removal of interstitial fluid thereby decreasing localized edema and increasing the blood flow [6]. Thus, decreasing the tissue bacterial levels. Also, the mechanical deformation of cells increases the rate of cell proliferation due to protein and matrix molecule synthesis [6]. The technique has yielded good results in the studies reported, and also this technique is comparatively cost effective as compared to the conventional treatments, particularly in wounds that are difficult to heal [6].

 

Clinical evidences

 

Negative pressure wound therapy using the VAC is one of the most important modes of treatment used in modern wound management [11-15]. A number of clinical studies, both on animals and humans have been done so far. Most of these studies have reported the use of VAC as at par and at times better with the conventional wound closure techniques [16]. Argenta and Morykwas in the year 1997 reported the results of their study on 300 human subjects of which 296 patients responded favorably to the VAC [4]. Similarly, numerous other papers have described the use of VAC in the treatment of a variety of wound types including soft tissue injuries prior to surgical closure [17], extensive degloving injuries [18,19], various grafting or reconstructive surgery [20] and infected sternotomy wounds [21-23]. Smith et al. 1997, in a retrospective review of open abdomen management and temporary abdominal closure, suggested the use of VAC as the treatment method of choice [24]. Vikatmaa et al. 2008, studied 14 RCTs and reported that in all trials, NPWT was at least as effective, and in some cases, more effective than the control treatment [25]. The same has been reported from other parts of the globe [26]. VAC has also been used in the treatment of donor sites, especially in areas that are difficult to manage by using conventional techniques [27] such as those of the radial forearm [28]. Andrabi et al. 2007, showed that usage of the VAC in the closure of laparotomy wound was much superior and quicker than conventional methodology [29]. VAC has also been used in conjunction with split thickness skin grafts in the treatment of burns and is claimed to be particularly useful for body sites with irregular or deep contours such as the perineum, hand or axilla [30-32]. Numerous case histories have described the successful use of VAC in a variety of non-healing or chronic wounds. These include a recalcitrant below knee amputation wound pressure sores [33-38] and a suspected Brown Recluse Spider bite [39], leg ulcers, and a group of 30 patients with longstanding wounds that were deemed unsuitable for reconstructive surgery, 26 of whom responded favorably to the treatment [40].

 

The method

 

The VAC involves a six step method. The following are the VAC steps, as detailed by Thomas in 2001 [6]: the foam dressing is cut to the approximate size of the wound with scissors and placed gently into position→ The perforated drain tube is then located on top of the foam and a second piece of foam placed over the top. For shallower wounds, a single piece of foam may be used and the drainage tube is inserted inside it→ The foam, together with the first few inches of the drainage tube and the surrounding area of healthy skin, is then covered with the adhesive transparent membrane supplied. At this stage it is important to ensure that the membrane forms a good seal both with the skin and the drainage tube →. The distal end of the drain is connected to the VAC unit, which is programmed to produce the required level of pressure→ Once the vacuum is switched on, the air is sucked out of the foam causing it to collapse inwards drawing the edges of the wound in with it→ Fluid within the wound is taken up by the foam and transported into the disposable container within the main vacuum unit [6].

 

Cost of treatment

 

Greer et al. 1999, discussed some of the practical problems associated with the application of the VAC system [37]. Although the technique appears to be very costly since it involves the expenditure on the purchase cost or hire charges of the VAC machine itself, besides it is necessary to purchase disposable foam dressings and drainage tubes, canisters and adhesive drapes, which together could easily cost in excess of 25 per day [6]. Yet the reports about the cost effectiveness of VAC are available in the scientific literature [41]. One reason could well be the time duration for the healing of the wounds which is shorter in the VAC as compared to the conventional methods. Moues et al. 2005, showed that NPWT had significantly higher material expenses (p < 0.001), but significantly lower nursing expenses (p = 0.043) [42]. Still further studies investigating the cost-effectiveness of VAC therapy compared with conventional methods of wound management are required in future.

 

The Indian perspective

 

The low income countries are having a number of issues related to public health [43]. The use of NPWT in the Indian studies has not been reported extensively. Only few Indian studies have provided insights into the NPWT use in Indian setting [16,44-46]. The NPWT using the VAC is definitely having an advantage in countries like India, where the patient load on the health centers is very high [47,48]. In countries like India, where more than 40% of the population earns less than one US dollar per day and where only a small portion of government budget goes to health there is an urgent need of faster and cheaper wound healing techniques [48-53]. The health care information about the newer and cheaper techniques will help a great deal in the exponentially growing population [47]. In such a scenario any wound healing technique that will work faster than the conventional techniques and deliver at par or at times better results is definitely a boon [16]. Hussain et al. 2012, reported that the VAC has certain advantages like it is easy to handle, hospital admission is not essential, good patient compliance and satisfaction, require minimal training to maintain vacuum at home, can be applied to multiple cases at the same time and give adequate mobility to the patient [16]. The VAC will also reduce the total time spent in the hospital and this is ideal for already overloaded hospitals [47]. Besides, the number of follow-ups will also be reduced in cases involving the VAC. But the situation in the rural areas is graver [54]. As, the VAC is not available everywhere in the developing countries and the usage of VAC in the rural areas is very difficult due to difficulties related to terrain, availability of devices, cost issues, etc. [46]. Thus the use of indigenous substitutes of the wound management which can be used in the rural areas of developing countries is essential [46]. Further the advantages and disadvantages of VAC are summarized in Table 1, as explained by Thomas in the year 2001 [6]. In the absence of larger studies with adequate sample size from various population groups the results available so far from the published studies suggest that the VAC is a promising technique. Further research will help in analyzing the cost effectiveness of the VAC over the conventional techniques. But till that time, the data available from scientific literature suggest VAC to be a cost effective technique, resulting in at par or at times better wound healing, with few serious complications.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors’ contributions Up    Down

All authors read and approved the final manuscript.

 

 

Table  Up    Down

Table 1: indications and contraindications for the use of VAC

 

 

References Up    Down

  1. Robson MC, Steed DL, Franz MG. Wound healing: biologic features and approaches to maximize healing trajectories. Curr Probl Surg. 2001;38(2):72-140. PubMed | Google Scholar

  2. Alonso JE, Lee J, Burgess AR, Browner BD. The management of complex orthopaedic injuries. Surg Clin North Am. 1996;76(4):879-903. Google Scholar

  3. Velnar T, Bailey T, Smrkolj V. The Wound Healing Process: an Overview of the Cellular and Molecular Mechanisms. The Journal of International Medical Research. 2009;37(5):1528-1542. PubMed | Google Scholar

  4. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563-577. PubMed | Google Scholar

  5. Fleischmann W, Strecker W, Bombelli M, Kinzl L. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg. 1993;96(9):488-492. PubMed | Google Scholar

  6. Steve Thomas. An introduction to the use of vacuum assisted closure . May 2001. Accessed 12 April 2016

  7. Banwell P, Withey S, Holten I. The use of negative pressure to promote healing. Br J Plast Surg. 1998;51(1):79. PubMed | Google Scholar

  8. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553-562. PubMed | Google Scholar

  9. Morykwas MJ, Argenta LC. Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc. 1997;6(4):279-288. PubMed | Google Scholar

  10. Fabian TS, Kaufman HJ, Lett ED, Thomas JB, Rawl DK, Lewis PL et al. The evaluation of subatmospheric pressure and hyperbaric oxygen in ischemic full-thickness wound healing. Am Surg. 2000;66(12):1136-1143. PubMed | Google Scholar

  11. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Education Program . 2001. Accessed 12 April 2016

  12. Bonham PA, Flemister BG, Droste LR, Johnson JJ, Kelechi T, Ratliff CR, Varnado MF. 2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary. 2016. Accessed 12 April 2016

  13. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum assisted closure: micro deformations of wounds and cell proliferation. Plast Reconstr Surg. 2004; 114(5):1086-1096. Google Scholar

  14. Armstrong DF, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomized controlled trial. Lancet. 2005; 366(9498):1704-1710. Google Scholar

  15. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005; 293(2):217-228. PubMed | Google Scholar

  16. Hussain A, Singh K, Singh M. Cost Effectiveness of Vacuum-Assisted Closure and its modifications: a review. ISRN Plastic Surgery. 2013; vol 2013(Article ID 595789): 5 pages. Google Scholar

  17. Bauer P, Schmidt G, Partecke BD. Possibilities of preliminary treatment of infected soft tissue defects by vacuum sealing and PVA foam. Handchir Mikrochir Plast Chir. 1998; 30(1):20-23. PubMed | Google Scholar

  18. Meara JG, Guo L, Smith JD, Pribaz JJ, Breuing KH, Orgill DP. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg. 1999; 42(6):589-594. PubMed | Google Scholar

  19. De Franzo AJ, Marks MW, Argenta LC, Genecov DG. Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg. 1999; 104(7):2145-2148. Google Scholar

  20. Avery C, Pereira J, Moody A, Whitworth I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg. 2000; 38(4):343-345. PubMed | Google Scholar

  21. Tang AT, Ohri SK, Haw MP. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg. 2000;17(4):482-484. PubMed | Google Scholar

  22. Obdeijn MC, de Lange MY, Lichtendahl DH, de Boer WJ. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg. 1999;68(6):2358-2360. PubMed | Google Scholar

  23. Tang AT, Ohri SK, Haw MP. Vacuum-assisted closure to treat deep sternal wound infection following cardiac surgery. J Wound Care. 2000;9(5):229-230. PubMed | Google Scholar

  24. Smith LA, Barker DE, Chase CW, Somberg LB, Brock WB, Burns RP. Vacuum pack technique of temporary abdominal closure: a four-year experience. Am Surg. 1997;63(12):1102-1107. PubMed | Google Scholar

  25. Vikatmaa P, Juutilainen V, Ukasjarvi P, Malmivaara A. Negative pressure wound therapy: a systematic review on effectiveness and safety. Eur J Vasc Endovasc Surg. 2008; 36(4):438-448. PubMed | Google Scholar

  26. Pham CT, Middleton P, Maddern G. Vacuum-assisted closure for the management of wounds: an accelerated systematic review. ASERNIP-S Report No.37 .2003. Accessed 12 April 2016

  27. Blackburn JH, Boemi L, Hall WW, Jeffords K, Hauck RM, Banducci DR et al. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;40(5):453-457. PubMed | Google Scholar

  28. Avery C, Pereira J, Moody A, Whitworth I. Negative pressure wound dressing of the radial forearm donor site. Int J Oral Maxillofac Surg. 2000;29(3):198-200. PubMed | Google Scholar

  29. Andrabi IH, Ahmad J, Rathore MA, Yousaf M. Vacuum assisted closure of laparostomy wounds a novel technique. J Ayub Med Coll Abottabad. 2007;19(3):89-91. Google Scholar

  30. Schneider AM, Morykwas MJ, Argenta LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg. 1998;102(4):1195-1198. PubMed | Google Scholar

  31. Pfau M, Rennekampff HO, Schaller HE. Skin graft fixation by vacuum assisted topical foam dressing. J Burn Care Rehab. 2000; 21(1):1. Google Scholar

  32. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg. 2000; 105(1):174-177. PubMed | Google Scholar

  33. Collier M. Know-how: a guide to vacuum-assisted closure (VAC). 1997. Accessed 12 April 2016.

  34. Deva AK, Siu C, Nettle WJ. Vacuum-assisted closure of a sacral pressure sore. J Wound Care. 1997;6(7):311-312. PubMed | Google Scholar

  35. Hartnett JM. Use of vacuum-assisted wound closure in three chronic wounds. J Wound Ostomy Continence Nurs. 1998;25(6):281-290. PubMed | Google Scholar

  36. Baynham SA, Kohlman P, Katner HP. Treating stage IV pressure ulcers with negative pressure therapy: a case report. Ostomy Wound Manage. 1999;45(4):28-32,34-35. PubMed | Google Scholar

  37. Greer SE, Duthie E, Cartolano B, Koehler KM, Maydick-Youngberg D, Longaker MT. Techniques for applying subatmospheric pressure dressing to wounds in difficult regions of anatomy. J Wound Ostomy Continence Nurs. 1999;26(5):250-253. PubMed | Google Scholar

  38. Mendez-Eastman S. Use of hyperbaric oxygen and negative pressure therapy in the multidisciplinary care of a patient with nonhealing wounds. J Wound Ostomy Continence Nurs. 1999;26(2):67-76. PubMed | Google Scholar

  39. Mendez-Eastman S. Negative pressure wound therapy. Plast Surg Nurs. 1998; 18(1):27-9:33-37. PubMed | Google Scholar

  40. Deva AK, Buckland GH, Fisher E, Liew SC, Merten S, McGlynn M et al. Topical negative pressure in wound management. Med J Aust. 2000; 173(3):128-131. PubMed | Google Scholar

  41. Philbeck TE, Whittington KT, Millsap MH, Briones RB, Wight DG, Schroeder WJ. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy Wound Manage. 1999;45(11):41-50. PubMed | Google Scholar

  42. Moues CM, van den Bemd GJ, Meerding WJ, Hovius SE. An economic evaluation of the use of TNP on full thickness wounds. J Wound Care. 2005; 14(5):224-227. PubMed | Google Scholar

  43. Yadav S, Rawal G. Self-medication practice in low income countries. International Journal of Pharmaceutical Chemistry and Analysis. 2015;2(3):139-142. Google Scholar

  44. Singh M, Singh R, Singh S, Pandey V, Singh D. Vacuum assisted closure in wound management-Poor man's VAC©,.The Internet Journal of Plastic Surgery. 2009;6(1): 164-169. Google Scholar

  45. Siddha LV, Shetty SK, Varghese T. Efficacy of modified vacuum assisted closure in wound healing. Int J Sci Stud. 2015;2(11):52-59. Google Scholar

  46. Ruke M, Puranik S, Pawar A. Indigenous negative pressure wound therapy for poor patients in India-an observational case series. The Journal of Diabetic Foot Complications. 2013;5(3):73-77. Google Scholar

  47. Yadav S, Rawal G. Healthcare information for all-Is it achievable?. Int J Sci Res Rev. 2015;4(1):101-105.

  48. Yadav S, Rawal G. Swine flu-have we learnt any lesson from the past?. Pan Afr Med J. 2015;22:118. PubMed | Google Scholar

  49. Yadav S, Rawal G. Counterfeit drugs: problem of developing and developed countries. Int J Pharmceut Chem Anal. 2015;2(1):46-50. Google Scholar

  50. Yadav S, Rawal G, Baxi M. An overview of the latest infectious diseases around the world. Journal of Community Health Management. 2016;3(1):41-43. Google Scholar

  51. Yadav S, Rawal G. The menace due to fake antimalarial drugs. Int J Pharmceut Chem Anal. 2016;3(1):53-55. Google Scholar

  52. Yadav S, Rawal G, Baxi M. Plagiarism-A serious scientific misconduct. Int J Health Sci Res. 2016;6(2):364-6. Google Scholar

  53. Yadav S, Rawal G, Baxi M. Zika virus: a pandemic in progress. J Transl Intern Med. 2016;4(1):42-45. PubMed | Google Scholar

  54. Yadav S, Rawal G. Role of integrating community health workers in achieving healthcare information for all. Int J Sci Res Rev. 2015;4(1):106-110.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


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Keywords

Negative pressure
Negative pressure wound device
VAC
Vacuum therapy
Vacuum sealing
Wounds
Wound closure
Wound healing

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