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Latar Belakang: Diantara berbagai cara pengobatan tambahan yang tersedia untuk penanganan lukakronis, terapi vacuum-assisted closure (VAC) menunjukkan hasil yang menjanjikan. Namun sistem terapiVAC ini mahal, membutuhkan produk dengan jumlah yang banyak serta sumber daya setiap kalipenggunaannya. Pada artikel ini, penulis memperkenalkan dan menguraikan pengalaman pengobatanluka kronis dengan simplest modified vacuum assisted closure (smVAC).

Metode: Tiga pasien dengan luka kronis datang ke Divisi Bedah Plastik Rumah Sakit dr. Sardjito padaawal tahun 2010, dilakukan perawatan dengan menggunakan simplest modified vacuum assisted closure(smVAC). Setelah siap, luka ditutup menggunakan split thickness skin graft (STSG) dan smVACmembantu proses penempelan graft.Hasil: Semua pasien mengalami proses penyembuhan luka dengan baik dan dilaporkan puas terhadaphasilnya. Tidak terdapat efek samping seperti maserasi, nekrosis, maupun perdarahan akibat alat yangdigunakan.Kesimpulan: Berdasarkan kasus serial ini, smVAC mampu menyediakan tekanan vakum yang adekuatpada luka. Alat ini dapat digunakan sebagai alternatif apabila tidak dapat menggunakan alat yang orisinil.Kata Kunci:chronic wound, vacuum assisted closure, split thickness skin graft, simplest modified vacuum assistedclosure

Background: Among the current adjunctive treatment modalities available for the treatment of chronicwounds, vacuum-assisted closure therapy showed promising results. However, the VAC Therapy systemis expensive, requires extensive amounts of product and needs a power source at all times. In this article,the authors introduce and review their experience with simplest modified vacuum assisted closure(smVAC) for treatment of chronic wound.Methods: Three patients with chronic wound came to the plastic surgery division at Sardjito hospital inearly 2010 and were treated using simplest modified vacuum assisted closure (smVAC). After the wound

bed was ready, split thickness skin graft (STSG) were performed to close the wound and smVAC was used

to assist the graft placement.Results: All patients underwent successful healing and reported satisfaction with their results. There wereno side effects from using this device, such as maceration, necrosis and bleeding.Summary: Through the serial cases, the smVAC had shown to serve its function in providing adequatevacuum pressure for wounds. It is an alternative to the original vacuum assisted closure.Keywords: chronic wound, vacuum assisted closure, split thickness skin graft, simplest modified vacuum assistedclosure

hronic wound poses an ongoingchallenge for its management. It is amajor source of morbidity, lead to

considerable disability, and is associated withincreased mortality. Therefore, it has asignificant impact on public health and theexpenditure of health care resources 1,2. Among

the current adjunctive treatment modalitiesavailable for the treatment of chronic wounds,vacuum-assisted closure therapy has shownpromising results. It is a new technique ofmanagement of wound based on the principleof application of controlled negative pressure3,4,5. It is frequently recommended for use withchronic wounds, acute and traumatic wounds,

!

From Division of Plastic Surgery, Department OfSurgery, dr. Sardjito Hospital, Universitas Indonesia.Presented in The 14th Annual Scientific Meeting ofIndonesian Association of Plastic Surgeon, Balikpapan,

East Kalimantan, Indonesia

The Simplest Modified Vacuum Assisted Closure toTreat Chronic Wound : Serial Case Report

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Disclosure: Neither of the authors has anyfinancial interests, sources of funds, commercialaffiliations, or associations related to the

publication of this article.

www.JPRJournal.com 117

Danu Mahandaru, Rosadi SeswandhanaYogyakarta, Indonesia.


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118

flaps, grafts, and other non-sutured woundssuch as dehisced incisions. The mechanism ofthis procedure is to reduce exudates andcolonization of bacteria, stimulate angiogenesis,increase perfusion, and stimulate granulationtissue 6,7,8. However, the VAC Therapy system has itsdisadvantages. It is expensive and requiresextensive amounts of product and machinery,as well as functioning suction, and a powersource at all times. In addition, the VACTherapy system requires a trained and vigilantnursing staff 1,3. To overcome those problems,the idea to invent a modification of VAC system

with simple, accessible, save, massivelyproduced and cheap materials took place. Themodification aimed to reach the same benefitsas the original one. In some countries the VACsystems modification were conducted by usingaccessible materials in each country as wellusing the device for different kinds of wound4,9. For example: Italia, 2001: Mobile-VAC for the treatment oflower limb ulcers. England, 2001: Inexpensive-VAC, employinga conventional disposable closed-suction

drainage system. Atlanta, 2001: Negative pressure dressings(by continuous wall suction) in treatment ofhidradenitis suppurativa

Japan, 2003: Topical negative pressure usinga drainage pouch without foam dressing for thetreatment of undermined pressure ulcers. Indonesia, 2005: A simple modified-VACsystem for improving skin graft survival, treatchronic wound, etc.

METHODS

MODIFICATION OF VACUUM ASSISTED

CLOSURE

The reference for modification was the

experience on modified vacuum assistedclosure in Jakarta 2005. Simplification of thedevice was conducted by changing themanometer indicator with the infused balloon.In vitro test was done using 20 Otsuka bloodtransfusion set (elastic ball type) as shown inFigure 1.

From the test above, the smVAC cannotquantify in exact the strength of vaccumpressure applied (with an estimated range

between 110 -390 mmHg ). The ne gati ve

pressure recommended for chronic ulcer is 125mmHg. The pressure indicator used for thisdevice was if one balloon was deformed theestimated pressure was 110 mmHg. A model

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of the device is shown in Figure 2 and thespecification listed in Table 1.

CASE 1

The first case was a male, 52 years oldwith a history of 25 years chronic wound at thelateral side of the right ankle region. The woundhad bad granulation tissue and necrotic tissue.First the wound was debrided, then smVACwas applied at the wound. After 7 days, thesmVAC was released, and the wound hadresulting good granulation tissue. Splitthickness skin graft used to cover the woundand the smVAC was used to assist graftplacement. Fifth day later, the smVAC wasreleased and the STSG adhere completely to thewound bed. On the tenth day, the graft hadsuccessfully covered the wound. (Figure 3)

CASE 2

The second case was a male, 24 years oldwith chronic wound at the posterior side of theleft ankle region. The wound was exudative,

with inadequate granulation tissue and exposed

sutures at the Achilles tendon. Debridementand refreshment of the wound by marginalexcision were done. Afterwards, the smVACwas applied to the wound. At the twelfth day,the smVAC was released and the woundalready had good granulation tissue and readyto be covered with skin graft. Split thicknessskin graft was used with the smVAC to assistgraft placement. Seventh day after STSG,vacuum was released and the graft took 100%in process. Finally, at the 13th day after STSG,the graft successfully covered the wound.(Figure 4)

CASE 3

The third case is 28 years old male, with4 months multiple chronic wound at the leftlower leg region. There were two wounds thathad necrotic tissue and boundary withunhealthy skin. First the patient underwentdebridement and refreshment of the woundedges. Then the smVAC was applied at thewound. At the fifth day, the vacuum was

released and the wound revealed good

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Specification Alternative

Negative Pressure Supply Unit Disposable Syringe 50 ml with three way infusion setDisposable unit Canister 100 cc closed rubber-sealed vacuum bottle

DressingSterile gaugeGrass tulle

Transparant Adhesive-Occlusive Dressing (tegaderm , opsite )

TubingConnector

Otsuka blood transfusion set (elastic ball type)

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granulation tissue and ready to be covered bygraft. Then split thickness skin graft were

performed and smVAC used again to assist the

graft placement. Ten days after STSG thevacuum was released and the graft took 100%

in process (Figure 5)

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Jurnal Plastik Rekonstruksi - March 2012


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RESULT

All patients underwent successfulhealing and reported satisfaction with theirresults. There were no side effects from usingthis device, such maceration, necrosis or

bleeding. Patient did not fell discomfort or painin using this device. Patients characteristics areshown on Table 2.

DISCUSSION

The use of a vacuum system (Vacuum-Assisted Closure, USA) to help wound healingwas introduced in 1997 by Argenta et al.Negative pressure seems to promote drainageof excessive fluids from the wound bed andinterstitial space, reducing bacterial populationand edema, enhancing local blood flow and

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Patient Sex Age Diagnosis Result TimePain/

discomfortSide

EffectSatisfy

1 Male 52 y.o Chronic ulcer atright ankle region

Fullhealing

12days

- - +

2 Male 24 y.o Chronic ulcer atposterior side of

ankle region(achilles)

Fullhealing

19days

- - +

3 Male 28 y.o Multiple chronic

ulcer at left lower leg

Full

healing

15

days

- - +

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granulation tissue formation. Other effect ofvacuum closure is to pull of the wound bordersto the center, reducing the wound diametersdue to retraction. Surgeons believe that thetreatment of difficult wounds should beprimarily surgical, and the VAC system wasreported to accelerate the preparation of thewound to definitive surgical closure. In otherwords, it improves the local conditions inpatients who are waiting a better clinicalsituation to be submitted to surgicalprocedures. The pressure is extremelyimportant.

With these concepts in mind, we

introduced in our service, the simplest modifiedvacuum assisted closure. The system was usedto treat 3 cases of difficult wounds, thuspreparing them to definitive surgical closure.The vacuum treatment aimed also to improvethe take of skin grafts. We are conducting aclinical trial on this subject. However, as ourfirst impression was quite positive, and wedecided to report this initial experience.

SUMMARY Through our serial cases, the smVACcannot quantify in exact the strength of vaccumpressure applied (we can only estimate a range

between 110-390 mmHg) but it has shown toserve its function in providing adequatevacuum pressure for wounds. The benefits ofour modified VAC is that it is cheaper and can

be constructed using simple clinical devices.This device can be used as an alternative device,if we could not use the original ones.

REFERENCES1. Simon Higgins, The effectiveness of vacuum assisted

closure (VAC) in wound healing. Centre for ClinicalEffectiveness Evidence Report (DRAFT), 2003.

2. Joseph E, Hamori CA, Bergman S, et al. A prospective,randomized trial of vacuum-assisted closure versus

standard therapy of chronic non-healing wounds;Wounds.2000;12(3)

3. Argenta LC, Morykwas MJ. Vacuum-assisted closure:

a new method for wound control and treatment:clinical experience. Ann Plast Surg. 1997;38(6):563-576;discussion 577.

4. Moues, CM, van den, Bemd GJ, Heule, F, Hovius, SE.Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospectiverandomised trial. J Plast Reconstr Aesthet Surg 2007;60:672.

5. Moues, CM, Vos, MC, van den, Bemd GJ, et al.Bacterial load in relation to vacuum-assisted closurewound therapy: a prospective randomized trial.Wound Repair Regen 2004; 12:11.

6. Mendez-Eastman, S. Guidelines for using negativepressure wound therapy. Adv Skin Wound Care 2001;

14:314.7. Meredith Warner, MD; Chance Henderson, MD;

Warren Kadrmas, MD; Darius T. Mitchell, MD.Comparison of Vacuum-assisted Closure to theAntibiotic Bead Pouch for the Treatment of BlastInjury of the Extremity. ORTHOPEDICS 2010; 33:77

8. KCI,V.A.C. TherapyClinicalGuidelines :A ReferenceSource for Clinicians, July 2007.

9. Melissa W. Kaufman, Douglas W. Pahl .Vacuum-assisted closure therapy: wound care and nursingimplications. Dermatology Nursing, August,2003

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M. Rosadi SeswandhanaPlastic Surgery Division, Department of Surgery,

Faculty of Medicine, Gadjah Mada University, Dr.Sardjito General Hospital, Yogyakarta, [email protected]

Jurnal Plastik Rekonstruksi - March 2012

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