Vacuum-Assisted Closure (VAC) Change for a Complex Right Hip Wound

CHAPTER 1

Hi, my name is Josh Ng-Kamstra. I'm a trauma acute care surgeon at Mass General. Today we're gonna be taking a patient to the operating room for a VAC change. It's not every VAC change that we do in the operating room, but for negative pressure wound therapy, for wounds that are more complex, or more involved, or that we want to take a really good look in the operating room under deeper anesthesia. Sometimes it's more appropriate to do these VAC changes in the OR rather than at bedside. So this gentleman in particular is a gentleman in his forties. He's had issues with joint and wound infections in the past. He unfortunately experienced paralysis in childhood due to complications of a spinal tumor. So he presented to hospital after having MSSA bacteremia, was found to have a complex infection of his right hip. Due to the fact that he is paralyzed, he was a candidate for a Girdlestone procedure, which is when the femoral head and the proximal aspect of the femur is resected. Not every patient is a candidate for this kind of procedure. As with that element of bone removed, the patient wouldn't be mobile or ambulatory. But for this patient, that operation would offer him the best chance of clearing infection. So the orthopedics team took him to the operating room a couple of days ago and did that procedure. And our team, the acute care surgery team, assisted with wound management and VAC placement. The most important part of planning for this kind of operation is to review the previous operating room note to know what kind of wounds you're expecting, what kind of management you'll have to do in addition to the dressing change. And perhaps most importantly, to know the number of foreign bodies that were left in the wound. In this case, the number of VAC sponges that were left in the wound. It's important to remove all of the VAC sponges before placing your new VAC 'cause if you have retained foreign bodies like that, they can get left behind in the wound for days or weeks and cause major problems for patients. So to prevent that kind of complication, it's important that both the surgeon and the operating room staff is well prepared knowing what needs to come out before a new VAC dressing goes in. So in this case, it was a complex wound due to the Girdlestone procedure with exposed bone. There were a total of five pieces of VAC sponge that were in the wound.

CHAPTER 2

We're gonna start by taking down these outside drapes. So I'm gonna maintain the sterile field as much as possible underneath this. Okay. Okay. Okay. And while he's intubated, or while he's under anesthesia, I'm gonna take the opportunity to get some of this hair off under here for - to protect his comfort in the future. Okay. Okay. Can I get a snap? Nope. Actually it's coming just fine. Yeah. These staples here. Yeah. Okay. Okay. So, okay. Okay. Okay. Okay. Okay, can I get scissors, actually? Yeah, okay. So just counting this here. So there's one, two, and then three pieces of sponge here. Okay. Actually, we're good here. And then I'm gonna take this off here. Chuck it in here. Okay. All right, back to you. Just kidding. I know. Thank you, thank you. We should shave a little bit of this down here and then we'll prep everything in with iodine. I'm all gussied up so I can shave him. And importantly, we have a little bit of give on his leg here so that we can move things around to get into the deep space of the leg. Thank you. Getting all the hair off makes subsequent dressing changes easier if you're not in the operating room. I think we're good. So then we'll prep the rest in with iodine and we'll take the other black sponges out when we have everything draped. You want just that one 3 L bag of saline? Yeah, I think just one 3 L bag should be good. Thank you. Okay, thank you. Okay, actually, I'm gonna move that top one because we wanna make sure that we have enough room for our plastic draping. We need some good overlap with the healthy skin on either side. There we go, okay. Okay. Okay, I just wanna make sure we can still move the leg around a little bit so we can really get in there. There we go. That's good. Okay. Okay, and again, I just wanna make sure we have enough room for our plastic to go down. Okay. Yep. VAC changes don't always have to be done in the operating room, but particularly for complex wounds, and for the first time that a VAC change is done, it can be really helpful to do it in the OR, especially for the acute phases of healing. You really wanna make sure that the sponge gets right into where it needs to be. If your sponge is too superficial and doesn't reach the base of the wound, you can have undrained parts of the wound that don't benefit from the VAC therapy. So that's one of the reasons why we do it in the operating room, at least for the first, once or twice we do it other than for simple wounds.

CHAPTER 3

Thank you. Okay. Okay. Can I get a snap as well? So, putting staples in the edge of the foam to the skin isn't always necessary. You know, the rule is that you want the foam to meet the edge of the subcutaneous tissue, but you don't want the foam to overlap the healthy skin because then it... So there's one piece of sponge that's out, okay. Okay. Yep. You can take that away. So you want the sponge to meet the edge of the skin, but not sit over the healthy skin itself 'cause it can damage the healthy skin further. So this is the results of the Girdlestone procedure. So we have the femur here with the femoral head removed. So, let's just be sure we have all of the black sponge, which is important. So that's the most important thing. Yep. So there's another piece of black sponge. So so far we had one deep piece, and then the second piece, which was on top, and then the three, yeah. So we matched that to our notes from the last time. So I just wanna be sure that there's nothing else under here. So now you can see exactly why we decided to do this in the operating room, just because it's such a deep and complex wound.

So we'll take the wound swab for culture. Yep. What would you like to call this, guys? Right hip, deep wound. Right hip, deep wound, all right. Just for an anaerobic and aerobic? Yep. All right. Okay. Okay. Sorry. Okay.

You want me to track, or? Can we get a ruler? Yep. Yeah, I'll just Put the ruler in. Okay. If you could put it on the side. Yeah. Yep. A little bit more to the side, a little bit. I'm sorry. Okay, yep. Great. Yep. And then do you want one across here? You can put it a little below the wound. Okay, okay. Awesome, great. Okay, and then, you know, it's deep, but I don't think you need a - do you need to do deep measurement? Yeah, I don't need it. Okay, okay. All right, back to you. Okay. So I'm just really examining this wound here just to be sure that there's no black sponge left anywhere else. Black sponge can feel surprisingly like tissue when it's full of fluid. So that is tissue there. And so I felt all the way behind here. Okay, I don't feel any more sponge. Okay, Dr. McElroy, do you want to have a feel as well? Never hurts to have more than one set of hands evaluate. Okay. Okay. Yep, I agree.

CHAPTER 4

And so for our next wound VAC, we're gonna attempt to do this in one piece rather than a couple just because that's a little bit more reliable in terms of making sure that the pieces come out. So - we'll have one at the top piece and then one that sort of sits on top of the bone and goes underneath, you know. Can we get some saline? We'll just give it a good wash out. And we'll get this suction. Oh, you have the suction there. Okay. Everybody have eye protection on? Yeah, okay. Yeah, can we get the kick bucket just underneath here? Yeah. Can we get more saline. Okay. Even better. Okay. Okay, we'll just wait for the kick bucket. Yeah, anything to decrease the bacterial load further. So the other thing that we're thinking about when we're doing this is, you know, subsequent VAC changes. You know, how are we gonna manage those? Is this ready to be done at bedside, or does this need to be done in the OR? The advantage with this patient is that this is not a painful wound for him given his his paraplegia, but nonetheless, it is quite an involved wound. And so I'm still concerned that in future wound changes we're still not gonna be able to do a safe, healthy debridement and VAC change just at bedside. So I think at least for the next OR we'll probably do it again in the OR. Okay, just a little piece of clot there or what? I think so. Can I get a curette? Do you have a curette? I'm just gonna muck this for a second. Yep. Okay. Good. I really wanna kind of see that pink healthy tissue. This is kind of thick fibrous tissue here, so it's not gonna end up being super pink. Okay, can we get a DeBakey? This is where this kind of just looks like clot here, which is gonna be a nidus for further infection. You want a rat tooth or a Bonney? Yeah, can I get a rat tooth? That's a good idea. What do you need? A rat tooth? A rat tooth. Rat tooth. Okay, can I get that curette again. Oops, sorry. Sorry. Okay. Okay. Okay, let me get just another dry sponge. Let me get the DeBakeys again. DeBakey. Yeah. Okay. Okay. Yeah, it's much better. Yeah. Got rid of all the non-viable tissue and clot. Sometimes a bit of rough debridement with a lap pad is your best bet for soft tissue like this. Ready for more? Yeah. This is just for a little bit of rough debridement, yeah. Yeah. Okay. Can I get a Poole sucker? If you don't, it's fine. It's fine, I think we're good. So the good news with this case is that it doesn't look like anything is like actively infected right now. It does look like there's a bit of non-viable tissue that is gonna benefit from us having been here in the OR just to do a bit of debridement. And this might seem a little rough on the tissue here, but that's precisely what'll sort of stimulate that little bit of edge bleeding and help with healing in the long run. Getting rid of all of that devitalized stuff on the surface. Okay. Okay. Nice. Okay. Okay. Okay, you happy with that Dr. McElroy? I am. Okay. Okay. Okay.

CHAPTER 5

All right, so we will get our black sponge now. You want a medium or a large? I think let's grab a large, and then we're gonna do arts and crafts with it. So we want to create a limb that will curl through? Yeah, I think so. So... Yeah, so we'll do like... An upper part and then a tail that curls down? Yeah, I love it. And then that may even just be enough if it's like a big thick piece of sponge, and then we will line the edges with the plastic. Yeah, yeah. Okay, that's a big cavity in there. So yeah, we're gonna have to keep coming to the OR to do this for a bit, I think. Yeah, and I'm happy that we got all of the sponges out, which is good. Do you want the strip ones or do you want to do the full - the bigger one? Don't you think like the circle one, if you kind of cut the edge off of it and then tunnel it down and then, you know. I feel like however you do your arts and crafts, you can make it work, but... Yeah, all stop efforts. Just make sure it's not bleeding too much here. Yeah. Looks okay. So she just kind of pushed it down onto the wound just to use the little outline of it to kind of establish where the edges of the wound are gonna be. And so Dr. McElroy is gonna kind of cut that shape out and then leave a nice long tail of it, attached to the main body of it so that we can tuck underneath. Yeah. Yeah. Yeah, yeah. We can always cut more off. There you go. And the for this, and then we can probably... And so we want to tunnel it under this - I think, yeah, tunneling it under this way. I think it makes more sense than tunneling it up to the top. Yeah, I can tunnel it this way. Do you think this is too much? Yeah, yeah. Do you want to trim it to here maybe? I think let's... Or do you want to just see how it looks first? Let's leave it for now. Here, let's just trim this bit a little bit so that this top bit will fit nicely. And I want to keep that tail nicely attached there. Yeah. Yeah. Yeah, so... That'll be nice down there. Yeah, and then that'll tunnel underneath here. We'll just give this a bit more of a trim. I just have to be careful with the black foam that you don't end up trimming little bits into the wound. Okay. Okay. Okay. Yeah. Yeah. Okay. Okay. Okay. Okay. All right, so let's just make sure that this nice tail fits way underneath there. So I'm gonna lift this up if you want. Can I get a packing sponge - or a packing forceps? Thank you, perfect. I think we can actually trim it down. Yeah, probably. Because that's what's there. Yeah, did it go any deeper if we lift it up? Like even if we like... Not really, I think I might be stenting the wound at that point if I do it. Do you know what I mean? Like if we go kind of like that. Okay. Yeah, because then I think that like really fills the space. Okay, so can we get - and I'm actually happy with that. I think we can just leave it in. Yeah, I think it fit there nicely.

CHAPTER 6

Can we get the plastic? And we're gonna cut little strips of this, so this is where the arts and crafts really starts. And actually, before we do that, let's staple that to the skin. So we'll get the stapler. I'll take the scissors in the meantime so I can start cutting some little... Okay. It's a two-fer stapler How many pieces did we do inside? Just one? Just one big one now. Yeah. So now what we're gonna do is we're gonna line the edges of the wound, and this just protects the skin from the effects of the suction. Yeah, and like Dr. McElroy was doing, the most important element of putting the plastic down is making sure that the skin is impeccably dry underneath. Would you like any Mastisol? I think we're actually okay. It's nice and dry here. So I'm just gonna put one more staple there. Yeah, let me get the stapler again. Yeah, that's good. Yeah. Okay, nice and then... Yeah, I have one there, and then one, just maybe one little, a little piece here. Yep. Do you want to do one corner piece here too? Yeah, might as well. Okay, thank you. Okay. Okay. All right, and then we'll get a piece of the plastic sheet, and take a chunk, how big do you want? Like - yeah, something like that. Yeah. I think we need like, yeah, a little more than half there. Yep. Okay.

CHAPTER 7

So, let's go from the bottom here. Okay. Yeah, and particularly for wounds around the bottom end, it's really important that the seal is good. Especially to avoid fecal soiling of this wound. I think we need a little bit more plastic just at the top here. A little strip maybe. So how is he gonna actually lie, you know? I think if we went here... Yeah, they had a little bit of a skin bridge. Yeah, no, I think that's reasonable.

CHAPTER 8

And can we get another little strip of the black foam? Okay. And so we'll bridge this. I'm just going to cut it so it like... I was going to put this over here to protect that. And then we'll cut it in. Okay. Okay, and then the... Yeah. Skin bridge to protect the skin. Okay, so, I'm cutting a hole in the plastic over this just so that this sponge has something to access in terms of a stream of suction. Okay, and then we'll go like this. Okay. We might. Probably need a second piece. Okay, good overlap there. Yep. And good. Okay. Okay. And just one more strip. Yep. Yep. Okay. Okay, this strip here should make it plenty. Scissors? Okay. Okay. Okay. Okay. Okay.

CHAPTER 9

This one is coming up. It's coming up a little bit? Okay, well I think it will be okay. I think it should be fine. Thank you. You're welcome. Is it okay if I take the Bovie? Mm hmm. Okay. Okay. Okay, and the reason why we did this whole skin bridge thing is because this piece, if the patient is laying or sitting on it, can be really damaging to the skin and soft tissues. Even if the patient is insensate, you don't want pressure, areas of high pressure sitting against the skin. So by putting a piece of plastic down and then bridging the foam off to here, when we connect this to suction, this suction will translate through this sponge and go into the wound itself there. Yep, so Dr. McElroy is just testing it. So see how when we apply the suction, all of this suctions in, and so that's gonna be really nice for helping this heal. And we're just gonna look at the edge here. Let's try - do you have a little piece here? Yeah, the thing with doing these, what you really get style points for is using just as much plastic as you need, but not too much plastic because that is uncomfortable for the patient and... Okay. Yep. And the more care you take with applying a VAC - that's good. That's good still, there's like a nice dry area here, so... The more care you take with a VAC when you put it on, the less trouble you'll have with leaking and other issues after the fact because that's the most common call from nursing staff when they're dealing with VACs is that there's a leakage alarm. Would you like it on regular VAC? Yes, can we wand so I can get the drapes off? And then the other important thing that Dr. McElroy did right away after we put the VAC on is applying suction as soon as possible. because what that does is it prevents, you know, there's always a little bit of blood and fluid, that if you leave it off suction for too long can start to accumulate up around the edges, and that's what destroys your seal. So, kind of keeping it on suction, and then once the VAC machine is ready, we'll transfer it over. Ready for 125 on low continuous? Perfect, yep. Yep, that's perfect. Yep. Thank you. Thank you. Okay. Okay. Perfect. Perfect.

CHAPTER 10

So we just finished the case. So, as you saw, once we'd positioned the patient on his left side so that we could fully access that right hip. We positioned him so that we knew we would have enough mobility in that right leg so that we could move the femur bone to make sure that we got all of the foreign bodies out from the deep wound space. So, we knew that there were five sponges that needed to come out, and we counted them all. I got to four and we thought we'd gotten them all, but we knew from the OR reports that there was another sponge. And indeed there was one that was very deep in the wound behind the proximal femur. You know, and those sponges can be a little bit deceiving. They can feel like regular tissue once they're full of fluid. But because we knew what we had to take out, we were able to get all of those VAC pieces out. Once we'd done that, we really made sure that the wound was nice and clean. Taking a patient to the OR allows you another opportunity to really clean out that wound. So we used 3 L of saline to fully wash the wound. We also made sure that we got rid of any devitalized tissue that would serve as a nidus for further infection. So we got rid of a little bit of wound debris at the edges of the wound using a combination of curette and sponge debridement, and then we got rid of a small hematoma as well. Any of those things can really lead to persistence of infection. Once we were happy that the wound edges were nice and healthy, there was a little bit of bleeding from those wound edges. Then we made our preparations to install the new VAC. So this time, we decided to just put one big piece of VAC sponge in, which will save a little bit of that headache of trying to count out all of the sponges for next time. So we cut the black sponge to size, leaving a nice long tail of sponge that could go deep into the wound behind the proximal femur. Once we'd done that, we used a stapler to approximate the sponge to the wound edges, protected the skin with the plastic dressing, and then put our plastic on top of our black sponge. We then made a skin bridge out to the side so that the patient wouldn't be laying on top of the suction device, which can cause issues like pressure wounds. Overall, I'm happy with how it went, I do think that this patient's next VAC change will, again, have to be done in the OR just because it is such a deep wound with such a high risk of recurrent infection to really make sure that for the next couple of times he has another good washout and VAC change. So that will be in another 48 to 72 hours, depending on how he's doing and when we can get him in.