PPT on negative pressure wound therapy/vac dressing for difficult abdominal wounds and burst abdomen.

1. N E G AT I V E P R E S S U R E
W O U N D T H E R A P Y
D R . D A N N Y D A R L I N G T O N
M S , M R C S E D , D N B ( U R O ) , M C H ( U R O )
F E L L O W I N U R O - O N C O L O G Y &
R O B O T I C S U R G E R Y
D E P A R T M E N T O F S U R G I C A L O N C O L O G Y
M A X H O S P I T A L , S A K E T , D E L H I

2. NPWT
Indications
Mechanism of
action
Components
Procedure
Complications
Contra-
indications

3. • One of the novel wound closure techniques
• pressure sores, venous ulcers, dehisced and acute wounds, and diabetic ulcers
• To secure skin grafts and flaps
• postoperative ascites and enterocutaneous fistulae
• The use of NPWT for achieving temporary cover of the open abdomen following
laparotomy for trauma is well established
• It facilitates early fascial closure with a decrease in the rate of large ventral hernias

4. I N D I C AT I O N S
• pressure sores, venous ulcers, dehisced and acute wounds, and diabetic ulcers*
• To secure skin grafts and flaps
• postoperative ascites and enterocutaneous fistulae
• Open postoperative abdominal wounds as temporary closure method
• Facilitate fascial closure/ delayed primary closure
* James SMD, Sureshkumar S, Elamurugan TP, Debasis N, Vijayakumar C, Palanivel C. Comparison of Vacuum-Assisted Closure Therapy and Conventional Dressing
on Wound Healing in Patients with Diabetic Foot Ulcer: A Randomized Controlled Trial. Niger J Surg 2019;25(1):14–20.

6. Bjorck Open abdomen classification
• Grade 1A Clean OA without adherence between bowel and abdominal wall or fixity of the
abdominal wall (lateralization of the abdominal wall).
• Grade 1B Contaminated OA without adherence/fixity
• Grade 2A Clean OA developing adherence/fixity
• Grade 2B Contaminated OA developing adherence/fixity
• Grade 3 OA complicated by fistula formation
• Grade 4 Frozen OA with adherent bowel, unable to close surgically, with or without
fistula
• Grades 3,4- High risk of fistulae after NPWT

10. M E C H A N I S M O F A C T I O N
Continuous negative pressure
• Macro-deformation, wound environment stabilization and decrease in edema
• Micro-deformation leading to increased cellular proliferation and angiogenesis
• Increases FGF beta, TGF beta, Il-8, VEGF in the wound
• Decreased bacterial load
• Removal of exudates as and when formed
• Promotes formation of new capillaries
• enhanced granulation cover

12. • can also reduce bowel edema
• lower intra-abdominal pressure in abdominal compartment syndrome

13. C O M P O N E N T S
• Sterile wet gauze
• Sterile foam (Polyvinyl alcohol, polyurethane foam) cut to the shape of the wound
• Adhesive polyurethane sheet
• Tubing with circular adhesive taping (Rhyles tube)
• Continuous wall mounted suction/ portable

14. VA C K I T S I N I N D I A
• KCI VAC therapy kit (includes al the components) Rs.90000
• Portable Suction device Rs.7500 to 15000
• Indigenous – Cheaper

16. P R O C E D U R E
• Wound bed filled with a saline-soaked sterile gauze piece after thoroughly cleaning
• VAC applied by placing sterile pads/foam in two layers with a 16Fr Ryle's tube placed
between the two layers
• wound sealed by a sterile transparent polyurethane sheet.
• Tube connected to a wall-mounted suction device and the pressure set at −125 mmHg
• Mode of NPWT: continuous
• Dressing changed every 48 h*
* James SMD, Sureshkumar S, Elamurugan TP, Debasis N, Vijayakumar C, Palanivel C. Comparison of Vacuum-Assisted Closure
Therapy and Conventional Dressing on Wound Healing in Patients with Diabetic Foot Ulcer: A Randomized Controlled Trial. Niger J
Surg 2019;25(1):14–20.

17. • Open abdomen -80 mm Hg*
• Standard pressure for extremity wounds- 125 mm Hg
• Children- 50 to 75 mm Hg
*Negative pressure wound therapy management of the “open abdomen” following trauma: a prospective study and
systematic review Pradeep Navsaria1, Andrew Nicol, Donald Hudson, John Cockwill and Jennifer Smith*World Journal of
emergency Surgery
*Stanirowski PJ, Wnuk A, Cendrowski K, Sawicki W. Growth factors, silver dressings and negative pressure wound
therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review. Arch Gynecol
Obstet. 2015;292(4):757–75.

18. W H E N T O S T O P. . ?
• when the goal of therapy had been met in terms of restoring integrity to the abdominal
wound
• when further therapy was considered to be futile because of a failure to progress after 2
weeks of therapy
• problems related to V.A.C. Therapy.

19. O U T C O M E O F VA C I N A B D O M I N A L
C L O S U R E
• Primary fascial closure 70-80%
• Mean closure days 6-10
• Complication rate 15%
• Fistula formation 5-7%
• Intra-abdominal abscess 4-6%
• Delayed intestinal obstruction 4%
Seidel D, Diedrich S, Herrle F, Thielemann H, Marusch F, Schirren R, et al. Negative Pressure Wound Therapy vs Conventional Wound
Treatment in Subcutaneous Abdominal Wound Healing Impairment. JAMA Surg. 2020 Jun;155(6):469–78.

20. C O M P L I C AT I O N S
• Bleeding if an open vessel in the vicinity of wound-mainly due to debridement opening
the vessel than the suction effect
• Pain: lignocaine gel can mitigate pain
• Peri-wound skin maceration: avoided by limiting foam size only to the raw area
• Dehydration in children
• Further wound dehiscence in immuno-compromised patients
• Suction loss: infection
• Poor sealing: loosening of drainage system

21. P R E V E N T I N G VA C P E R F O R AT I O N S
• Low pressure of -80 mm Hg for the abdomen
• Alternate day thorough wound inspection
• Avoid VAC on Bjorck type 3 and 4 abdomens

22. C O N T R A I N D I C AT I O N S
• Necrotic tissue with eschar
• Exposed nerves and solid organs
• Undernourished patient
• Severe pain
• Malignant wound
• Non-enteric fistula
*Safe in patients on anti-coagulants

23. General factors need to be taken care of during the healing phase.
Good enteral nutrition
NPWT doesn’t take care of the patient’s general factors
(smoking,diabetes,anemia,hypoalbuminemia)

27. Thank you