EUROPEAN  TISSUE  REPAIR  SOCIETY

Prof Luc Téot
Service des Brûles, Hôpital Lapeyronie, 371 Avenue du Doyen,
Giraud, 34255 Montpellier, France

Surgical debridement remains the gold standard concerning wound bed preparation. Unfortunately, this technique suffers from insufficient knowledge by the different practitioners. The lack of equipment in cauterisation or even in surgical tools, and the fear to go too far are generally the most common reasons of abandoning this technique or turning to alternative methods. The two principles no pain, no bleeding have to be reinforced.

How to debride using a scalpel, scissors and forceps?

• In case of a hard necrotic pressure sore: start by the centre using a scalpel, digging a small hole, then extend peripherally using the scissors.
• When sloughy tissue, more or less infected, is localised above an undermined pressure sore cavity, scissor debridement of the largest part of this potentially infection material must be done. This difficult situation can also necessitate a real surgical debridement in the operating room.
• Debridement of leg ulcers is more problematic, as pain is quickly limiting the possibility to remove an adherent fibrotic tissue.
• Debridement of diabetic foot ulcers is generally painless, the problem here being where to stop, as the wound does not present a normal aspect and not to provoke damage to this poorly vascularised tissue.

How to manage pain during surgical debridement?

• Prepare the patient psychologically, explaining exactly what will be done and how to participate and dialogue with the practitioner.
• Give antalgic drugs before the dressing, using morphine derived products if necessary. Use local antalgic cream, applied more than ninety minutes over the exposed area. The action is limited in depth to 2 to 5mm, but can be extended using painless injections of lidocain.

How to manage bleeding during surgical debridement?

• Prevent bleeding by careful handling of the tissues.
• When a small artery or vein is severed, use mechanical compression for three minutes, and if persistent, apply alginates locally to induce hemostasis.
• The first dressing will be done using alginates and a mild compression by gauzes and adhesive are applied.
• In case of severing a large vein, stitches will be necessary.

In the operating room:

A cancer-like debridement must be realised, largely extending the debridement to the peripheral healthy normal bleeding structures. Cauterisation is carefully and completely realised. In neurologic deficient patients, this technique can be done without anaesthesia, and sometimes precedes a surgical flap procedure or covering.

Surgical debridement offers a quick solution to clean the wound from germs and sloughy infected tissues for practitioners trained to these techniques.

Dr Ulrich Ziegler
Chirurgische Universitatsklinik, Joseph-Schneider Strasse 2,
97080 Wurzburg, Germany

In the last two decades new scientific and clinical findings led to a differentiated and multidisciplinary wound management in the paired as well as in the impaired wound healing. The aim is to optimise the wound bed in order to accelerate the wound healing with a functionally and cosmetically satisfactory result. A careful, regularly and efficiently performed debridement is absolutely necessary for the wound bed preparation.

Although classical surgical debridement is rated high in the treatment of chronic wounds, the importance of enzymatic debridement is increasing. Proteolytic enzymes do not only serve wound debridement, but also play an additional important role in regulation mechanisms of the wound healing. Several topically applicable enzymes are commercially available and they are suitable for the debridement in different ways.

At present the bacterial collagenase seems to be favourable because of a high specific affinity to all important types of collagen (1–V), an increased chemotaxis, the ability of activating macrophages and the prevention of pathological scar formation. The first results with Krill enzymes show good debriding effect.

The indications for an enzymatic treatment becomes more and more extended because of elderly patients. Regular surgical interventions in these patients are often not possible. Chronic wounds and burns (also in children) get enzymatically debrided if the necrotic zone is thin, in ulcers with pockets and as an additional measure to surgical bed-side-debridement in order to obtain wound closure and wound bed preparation. The combination of collagenase and hydrogels in different mixtures seems to be a good regulation of the secretion of the wounds before transplantation. Also they seem to decrease maceration of the skin. Collagenase in combination with alginates or hydro-colloids/polyurethane foils seem to have clinically syner-gistic effects.

Further clinical or animal experimental studies will need to be done in order to prove the efficiency of the best collagenase concentration or the effect of a combination with matrix binding proteins. Enzymes of animals and plants will have to be examined to produce selective, safe and efficient products. The costs regarding the different possibilities of debridement have to be evaluated in view of adjuvant therapies.