Journal of Pediatric Surgery (2006) 41, 940 942

www.elsevier.com/locate/jpedsurg

Vacuum-assisted closure for wound management in

the pediatric population
Andreana Butter, Mohammad Emran, Ayman Al-Jazaeri, Alain Ouimet*
Division of Pediatric Surgery, Sainte Justine Hospital, Montreal, Quebec, Canada H3T 1C5
Index words:
Vacuum-assisted closure;
Wound care;
Pediatric

Abstract
Background/Purpose: Wound management in children has traditionally consisted of daily dressings.
Although vacuum-assisted closure (VAC) is well described in the adult literature, there are few reports
about children. We reviewed our experience with VAC.
Methods: A retrospective review from 2003 to 2005 revealed that 16 children underwent VAC.
Variables analyzed included demographics, diagnosis, duration and characteristics of VAC, wound
closure, recurrence, complications, and cost analysis.
Results: Sixteen children received VAC therapy at an average age of 12.1 years (range, 1 month
18 years). Indications included tissue loss after pilonidal sinus excision (n = 8, primary = 5, recurrent =
3) after wound dehiscence of the abdomen (3), the sternum (2), the back (1), the leg (1), and after
chronic postoperative perineal fistula. Average length of VAC use was 23 days, with an average pressure
of 104 mm Hg. Wound closure occurred in 15 of 16 patients. Patients with primary pilonidal disease
obtained wound closure by 45 days, whereas those with recurrent disease required 72 days. Children
with wound dehiscence healed by 28 days. Recurrent sinuses developed in all 3 patients with known
recurrent pilonidal disease. Pain in 1 patient required cessation of VAC therapy after 7 days. Follow-up
after wound closure averaged 8 months.
Conclusions: Vacuum-assisted closure is well tolerated in our pediatric population and offers many
advantages including fewer dressing changes and an earlier return to daily activities.
D 2006 Elsevier Inc. All rights reserved.

Pilonidal sinus excision along with wound dehiscence in

children results in large soft tissue defects that can be left to
heal by secondary intention. Traditional management of
these wounds consists of daily to thrice daily wet-to-dry
dressings. Vacuum-assisted closure (VAC), initially described by Morykwas et al [1,2] in 1997, has been reported

Presented at the 37th Annual Meeting of the Canadian Association of

Paediatric Surgeons, Quebec, Canada, September 22-25, 2005.
* Corresponding author. Tel.: +1 514 345 4688; fax: +1 514 345 4964.
E-mail address: amouimet@videotron.ca (A. Ouimet).
0022-3468/$ see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2006.01.061

in the adult literature as a novel method of accelerating

wound healing. However, few reports exist about children
[3-5]. The VAC technique consists of insertion of an opencell foam sponge to the wound, sealing with an adhesive
drape, and subsequent application of negative, subatmospheric pressure, usually at 125 mm Hg [2]. Vacuumassisted closure promotes wound healing by removing
localized edema, which improves vascular and lymphatic
flow by reducing bacteria density, by promoting angiogenesis, and by increasing granulation tissue formation [1,2].
We report our experience with VAC in 16 children and
adolescents with major soft tissue wounds.

Vacuum-assisted closure for wound management

941

1. Materials and methods

After institutional review board approval, the charts of all
patients treated at Sainte Justine Hospital with a VAC device
(KCI Medical Canada, Mississauga, Ontario) were
reviewed. Sixteen children received VAC therapy since its
initiation at our institution in November 2003. Data
analyzed included patient demographics, indications, duration and characteristics of VAC therapy, wound closure,
recurrence, complications, and follow-up information.
The VAC device was used in conjunction with either
white or black sponges to fill the soft tissue defect. The
choice of sponge was based on the discretion of the
enterostomal therapist and patient comfort. The white
sponge contains more numerous, smaller holes and is
therefore considered to be less painful. The black sponge
has larger holes to remove more copious amounts of
drainage. Patients with pilonidal sinus were either initiated
with VAC at the bedside after 24 to 48 hours of wet-to-dry
dressings or treated as outpatients as soon as possible. For
patients with wound dehiscence, VAC was started once the
wound was deemed clean, based on appearance, by the
enterostomal therapist and the surgical team.

2. Results
Sixteen patients received VAC therapy at an average age
of 12.1 years (range, 1 month18 years) (Table 1). There
were 7 boys and 9 girls. Indications for use included tissue
loss after pilonidal sinus excision (5, primary; 3, recurrent),
after wound dehiscence of the abdomen (3), the sternum (2),
the back (1), the leg (1), and after chronic perineal fistula
post abdominoperineal resection (1). Average length of VAC
use was 23 days, with an average pressure of 104 mm Hg.
Vacuum-assisted closure therapy was used until regression
of 90% or more of the wound was observed (Fig. 1A-C).
Complete wound closure occurred in 15 of 16 patients. For
Table 1

Patient characteristics

Age
Sex (male/female)
Indications (n)
Pilonidal sinus excision
Wound dehiscence
Chronic fistula
Length of VAC use
Average pressure
Wound closure (n = 15 [94%])
Primary pilonidal sinus
Recurrent pilonidal sinus
Wound dehiscence
Complications (n)
Pain
Failure of wound closure
Recurrent pilonidal sinuses

12.1 y
7:9
8
7
1
23 d
104 mm Hg
45 d
72 d
28 d
1
1
3

Fig. 1 (A) Pilonidal sinus after excision. (B) with VAC in place.
(C) wound closure post VAC.

patients with primary pilonidal disease, wound closure

averaged 45 days, whereas those with recurrent disease
required 72 days. For patients with wound dehiscence,
healing was achieved in 28 days (Table 1).
Our 5 complications included severe pain and premature
cessation of VAC in 1 patient, failure of wound closure in
another patient, and recurrent pilonidal sinuses in 3 children.
After 7 days of VAC, 1 patient refused to continue treatment
despite having been offered the use of a less painful sponge
and decreased negative pressure. Wound closure never

A. Butter et al.

942
occurred in another adolescent with a chronic perineal
fistula (previous abdominal perineal resection for complicated Hirschsprungs disease). His VAC was placed in the
operating room after reexcision of his fistula. Cessation of
VAC occurred after 12 days because the fistula was only
1 cm deep. However, this area never completely healed,
necessitating reexcision and primary closure. Almost 1 year
later, his perineum remains healed with no demonstrable
fistula. Finally, recurrent pilonidal sinuses only developed in
those 3 patients with known recurrent diseases. Their
sinuses occurred at 2, 4, and 9 months after VAC and
complete wound closure. In contrast, none of the patients
with primary pilonidal sinuses nor any of the patients with
wound dehiscences developed recurrences post VAC. One
patient died before complete sternal wound closure, but after
cessation of VAC therapy, because of complications of his
severe congenital cardiac disease.

3. Discussion
Since 2003, VAC therapy has been used routinely at our
pediatric institution by several surgical services. Vacuumassisted closure was well tolerated in 15 of our 16 patients.
In adults, several case reports and small series document
the advantages of VAC therapy [2,6,7]. In contrast, very
little has been written about VAC use in children [3-5].
Caniano, using VAC, treated 51 children with various
complex wounds. Obese patients with primary pilonidal
disease healed by 45 days, whereas lean adolescents took
30 days; those with recurrent disease obtained wound
closure by 62 days, whereas lean adolescents had closed
wounds by 38 days on average. In our series, complete
wound closure took slightly longer because those with
primary pilonidal disease averaged 45 days, whereas those
with recurrent pilonidal disease averaged 72 days. This is
most likely a reflection of 2 factors: (a) several patients in
both groups were obese (3 of 5 in the primary pilonidal
group and 1 of 3 in the recurrent sinus group) and (b) a
delay in the onset of VAC. Unlike Caniano, we did not
install VAC intraoperatively, but rather an average of 6 days
later, because of logistic issues with Medicare in obtaining
the portable VAC device while the patient was still
hospitalized. In addition, our overall recurrence rate was
100% in those patients with already established recurrent
pilonidal disease. Caniano noted 3 of 12 recurrences,
whereas we observed 3 of 3 recurrences. We believe this
high recurrence rate is because of several factors including
delayed onset of VAC, chronic, nonhealing wounds before
VAC, and patient discomfort requiring cessation of VAC.
The first patient only began VAC therapy 7 months after
reexcision and failed medical treatment of her chronic sinus,

whereas the second patient started VAC 21 days after

reexcision but required 145 days to obtain wound closure.
Finally, our third patient stopped VAC therapy after only
7 days because of increasing pain and unwillingness to try
less painful modifications.
Vacuum-assisted closure has also been described for
closure of dehisced wounds in the sternum [4,5], the
abdomen [3,4], the extremities [3,4], and the back [4].
Similarly to Caniano et al [3] and Mooney et al [4], VAC
helped to achieve wound closure in 15 of our patients
within 11 days of VAC cessation without any recurrences or
patient discomfort, although 1 patient died before complete
skin healing.
Vacuum-assisted closure also seems to be more costeffective than daily dressings [8]. Given that the VAC
dressing is only changed 3 times weekly, nursing costs are
substantially less. Despite higher material costs (VAC unit
rental/purchase and foam dressings), our enterostomal
therapist estimated the cost of VAC to be almost 50% less
than traditional therapy in our health care system.
Vacuum-assisted closure offers many advantages over
traditional dressings for large wounds in children. Fewer
dressing changes result in increased patient comfort,
whereas the portable VAC device and nonbulky dressing
enable children and adolescents to rapidly return to their
daily activities.

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