Negative Pressure Wound Dressing Application 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Negative pressure therapy is very helpful in 
appropriate wounds. The beneficial effects on wound 
healing and promotion of healthy granulation tissue 
are well studied. Here, we demonstrate one way to 
adapt this technique to a resource-limited setting. In 
this chapter will demonstrate placement on a leg, but 
this technique is equally adaptable on an arm or other 
parts of the body, as long as a reliable seal can be 
maintained.  
This technique is contraindicated in wounds 
with purulent discharge or ongoing infection. You 
may be tempted to use it to control the drainage, but 
the system will be quickly overwhelmed. It is quite 
useful for wounds with dry eschar and non-infected 
debris, however. It is applied immediately after 
debridement. Negative pressure therapy’s properties 
can be used to promote granulation over tissue where 
it does not grow normally, such as exposed tendons.  
Some surgeons apply a negative pressure 
dressing immediately after a skin graft: this 
technique can promote graft take, especially in 
uneven surfaces like the hand and fingers. However, 
if your electricity or suction are not reliable, we 
suggest you use a different technique to apply 
continuous gentle pressure to your fresh grafts. See 
Split Thickness Skin Grafting. 
A source of suction is required: a portable 
electric machine can be used in areas where wall 
suction is not reliable. There are numerous reports of 
adapting a simple aquarium pump to provide suction, 
though we have no personal experience with this 
technique. A mechanical bellows system that needs 
no electricity is briefly described in the “Pitfalls” 
section below.  
On commercial devices such as the KCI 
Wound Vac (Kinetic Concepts Inc., San Antonio TX 
USA,) the amount of suction is adjustable and tightly 
regulated. In our experience, it is more important to 
have continuous suction of any amount, than to have 
a specific value. We have noted that negative 
pressure ranging from 20mmHg (or less) up to 
100mmHg yields an acceptable result.  
Another necessary ingredient is thin plastic 
sheeting: ordinary plastic wrap is quite sufficient in 
most situations, especially where it is applied 
circumferentially on an arm or a leg. Ordinary tape 
can be applied on the edges: make sure the skin is 
clean and dry, and apply alcohol and let it dry before 
applying the tape. In these examples we have used 
Ioban® adhesive plastic.  
Negative pressure closure of the open 
abdomen is done differently than described here: see 
Temporary Abdominal Closure. 
Application of a negative therapy proceeds in 
the following steps: 
● Appropriate selection and debridement of the 
wound 
● Placement of gauze impregnated with Petroleum 
Jelly (such as Vaseline ®.) 
● Placement of generous amounts of dry gauze 
● Coverage of the gauze with plastic wrap, secured 
at the edges. 
● Insertion of a tube through the plastic wrap, into 
the gauze 
● Connection to suction and confirmation that all 
of the gauze collapses. 
 
Steps: 
1. Debride the wound until there is minimal eschar 
remaining. If there is exposed tendon, make sure 
it is clean. Make sure all of the adjacent skin is 
clean and dry. 
 
Most eschar and all dead tissue should be debrided before the 
wound vac is applied. Exposed tendons can be preserved. These 
might be partially or completely covered with granulation 
tissue after the vac is removed in 5 days.  
 
2. Apply petroleum jelly gauze to all of the wound.  
Negative Pressure Wound Dressing Application 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
We make our own petroleum jelly gauze by impregnating plain 
gauze with jelly in a reusable sterilizable container.  
 
 
All of the wound is covered in petroleum jelly gauze.  
 
3. Generously cover the entire wound with several 
layers of dry gauze. This layer will transmit 
negative pressure to all of the wound.  
 
Plain gauze is applied in several layers to the wound. It is useful 
after this step to clean the exposed skin again and wipe it with 
alcohol, prior to applying plastic wrap or tape, to be sure no 
petroleum jelly is there to keep the tape from adhering.  
 
4. Cover the gauze in plastic wrap, such as available 
in a food store. Wrap or cover with 8-10 layers 
and overlap the edges of the gauze by at least 
5cm.  
 
Wrap or lay 8-10 layers of plastic wrap. 
 
5. Trim a nasogastric tube so there are extra holes 
near the end.  
 
Fold the tubing in half and cut off one corner, making an extra 
side hole in the tubing.  
 
6. Cut the plastic wrap in one corner with scissors 
and insert the cut end of the nasogastric tube. 
Negative Pressure Wound Dressing Application 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Cut the plastic wrap in one place with scissors. Then use the 
tips of the scissors to create a “tunnel” in the gauze so that the 
tube will fit inside and transmit even, continuous negative 
pressure to all of the gauze. 
 
 
The tube should be inserted through the plastic wrap to lie 
completely within the gauze.  
 
7. Using tape or adhesive plastic sheeting, make an 
airtight seal where the tube enters the plastic 
wrap. 
 
Adhesive plastic sheet has been cut into a smaller piece and a 
seal is created at both the tube insertion site and the adjacent 
edge of the plastic wrap. It is also possible to use adhesive sheet 
wrap to cover all of the gauze, but this is more expensive than 
using plastic wrap for most of it and sealing only the edges with 
the adhesive wrap. 
 
8. Using tape or adhesive plastic, cover the edges of 
the plastic wrap and assure a good seal. If you use 
tape, be sure to use a generous amount and assure 
that the skin is clean.  
9. Connect the tubing to suction and confirm that all 
of the gauze and plastic wrap grips tightly onto 
the area it is applied.  
 
When suction is applied, the gauze is seen to “wrinkle” and 
become firm. If this does not occur, search for a leak in the 
system.  
 
10. Verify every day that the vacuum seal remains in 
place. Open the dressing after 5 days and either 
graft or place a new dressing, depending on the 
appearance of the wound.  
 
Pitfalls 
Negative Pressure Wound Dressing Application 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Do not use negative pressure therapy on infected 
wounds or those with purulent discharge.  
● Verify that the suction continues to function 
throughout the 4-5 days that the dressing is in 
place. If suction is interrupted, the wound can 
worsen if left closed for an extended amount of 
time.  
● It is common in resource-rich settings to apply a 
negative pressure dressing directly over a skin 
graft after applying it. We would only 
recommend such a strategy if the electricity and 
suction were reliable, as a loss of suction could 
compromise the graft. Certainly the team should 
examine the dressing twice daily, to make sure 
the negative pressure remains until the graft is 
unveiled.  
● This technique depends on a continuous and 
reliable source of suction, which in turn depends 
on continuous and reliable electricity. Various 
solutions have been proposed, including a 
bellows device such as the one shown below. 
With such a device, a proper seal is more 
important, as a continuous slow leak is not 
tolerated.  
 
 A high volume bellows for negative pressure wound therapy in 
settings without reliable electricity. Source: Sorm K et al, J 
Orthop Trauma. 2015; 29(10):S33–S36.  
https://doi.org/10.1097%2FBOT.0000000000000410  
 
● Do not apply a negative pressure dressing to large 
exposed blood vessels such as the femoral 
arteries or veins. Mobilize some adjacent muscle 
to protect the vessels from the gauze and adherent 
dressing.  
● Do not apply a negative pressure dressing 
directly to exposed intestine.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
September 2022 
