Limited Access Dressing

Professor Pramod Kumar, MS, MCh, DNB

Limited Access Dressing (LAD): The Concept and Applications

How is LAD a combination of moist healing and negative pressure dressing? The Limited Access Dressing is a combination of intermittent negative pressure (for 30 minutes) and a moist wound dressing (for 31⁄2 hours without negative pressure) that is covered with a transparent polythene material (a total of 3 hours moist dressing and 21 hours negative pressure dressing in a 24- hour period). Negative pressure (up to -30 mmHg) is applied through tubing connected to a suction machine that is then placed under a polythene wound cover.

LAD designs. The material that contacts the wound LAD is classified into 2 groups:

A. Hydrocolloid material contacts the wound (LAD I, Figure 1)

B. Polythene sheet contacts the wound (LAD IB and LAD II, Figure 2)

Some may be skeptical as to whether a hydrocolloid material encountering the wound or negative pressure (LAD I) makes a difference. Liquefied hydrocolloid materials blocking the tube, and poor wound floor visibilityfor the initial few days until the suction removes any liquefied material, are two additional problems.

To avoid doubts and problems associated with LAD I, in LAD IB (Figure 2) a sterile polythene sheet separates the wound along with tubes from hydrocolloid and in the Hydrocoll® (Hartmann, Heidenheim, Germany) a central hole was made to improve visibility. LAD I and LAD IB was used for smaller wounds (up to 10 cm x 10 cm given that the maximum size of Hydrocoll was 15 cm x 15 cm).

In LAD II (Figure 3) wounds are covered with larger polythene sheets, polythene tubes, and polythene bags after placing tubes (as in other LAD designs) and when sealing is achieved with pieces of Hydrocoll and the adhesive polyurethane film (OpSite, Smith & Nephew, Largo, Fla).

If required in critically ill patients, after taking out intravenous and other lines through the LAD polythene bag that covers the extremities, the puncture site may be sealed effectively.

How much intra-LAD negative pressure is effective? There is a general belief among most physiologists that true interstitial fluid pressure in loose subcutaneous tissue is slightly less than atmospheric pressure (average value of this pressure is negative in relation to atmospheric pressure and is approximately -3 mmHg).35

When the skin cover is absent in wounds,the pressure will rise to 0 mmHg (ie, equal to atmospheric pressure). These increases in interstitial tissue pressure from -3 mmHg to 0 mmHg will also cause the lymph flow to increase 20-fold35 and the re-absorption of fluid to increase through capillaries. Hence, the chances bacterial invasion and absorption of chemicals (toxins) through venules and lymphatics increases when edema increases the interstitial tissue pressure or produces an open wound that is not sutured.


1. Alvarez OM, Mertz PM, Eaglstein WH.The effect of occlusive dressings on collagen synthesis and re-epithelialization in superficial wounds. J Surg Res. 1983;35(2):142–148.
2. Winter GD.Epidermal regeneration studied in the domestic pig. In: Maibach HI, Rovee DT, eds. Epidermal Wound Healing. Chicago, Ill:Year Book Medical Publishers; 1972: 71–112.
3. Bennett RG.The debatable benefit of occlusive dressings for wounds. J Dermatol Surg Oncol. 1982;8(3):166–167.
4. Geronemus RG,Robins P.The effect of two new dressings on epidermal wound healing. J Dermatol Surg Oncol. 1982;8(10):850–852.
5. Ryan TJ. Current management of leg ulcers. Drugs. 1985;30(5):461–468.
6. Gilchrist B, Reed C.The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressings. Br J Dermatol. 1989;121(3):337–344.
7. Winter,GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293–294.
8. Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature. 1963;200:377-378.
9. Aly R, Shirley C, Cunico B, Maibach HI. Effect of prolonged occlusion on the microbial flora,pH,carbon dioxide and transepidermal water loss on human skin. J Invest Dermatol. 1978;71(6):378–381.
10. Marples RR, Kligman AM.Growth of bacteria under adhesive tapes. Arch Dermatol. 1969;99(1):107–110.
11. Turner TD. Semi-occlusive and occlusive dressings. In: Ryan TJ, ed. An Environment For Healing: The Role of Occlusion. London: Royal Society of Medicine; 1985:5–14.
12. Eriksson E. Comparative study of hydrocolloid dressing and double layer bandage in treatment of venous stasis ulceration. In: Ryan TJ, ed. An Environment For Healing: The Role of Occlusion. London: Royal Society of Medicine; 1985:45–49.
13. Finegold SM. Pathogenic anaerobes. Arch Intern Med. 1982;142(11):1988–1992.
14. Allen S. Leg ulcers and their management. Nurs Times. 1985;81(25):49–56.
15. Alper JC,Welch EA, Ginsberg M, Bogaars H, Maguire P. Moist wound healing under a vapor permeable membrane. J Am Acad Dermatol. 1983;8(3):347–353.
16. Leaper D. Leg ulcers.Antiseptics and their effect on healing tissue. Nurs Times. 1986;82(22):45–47.
17. van Rijswijk L, Brown D, Friedman S, et al. Multicenter clinical evaluation of a hydrocolloid dressing for leg ulcers. Cutis. 1985;35(2):173–176.
18. Weston-Davies WH. Clinical aspects of Granuflex dressings. In: Turner TO, Schmidt RJ, Harding KG, eds. Advances in Wound Management. Chichester: John Wiley and Sons; 1986:101–107.
19. Eriksson G, Eklund AE, Kallings LO. The clinical significance of bacterial growth in venous leg ulcers. Scand J Infect Dis. 1984;16(2):175–180.
20. Urbano P, Dei R, Tarantelli F, Mazza A. Epidemiological studies of Pseudomonas aeruginosa infections in leg ulcers. Med Microbiol Immunol. 1983;172(1):41–45.
21. Brennan SS, Leaper DJ. The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. Br J Surg. 1985;72(10):780–782.
22. Argenta LC, Morykwas M, Rouchard R. The use of negative pressure to promote healing of pressure ulcers and chronic wounds in 75 consecutive patients. Presented at the Joint Meeting of the Wound Healing Society and European Tissue Repair Society,Amsterdam, 1993.
23. Fleischmann W, Strecker W, Bombelli M, Kinzl L. [Vacuum sealing as treatment of soft tissue damage in open fractures] Unfallchirurg. 1993;96(9):488–492. [Article in German].
24. Mullner T, Mrkonjic L,Kwasny O,Vecsei V.The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997;50(3):194–199.
25. Avery C, Pereira J, Moody A,Whitworth I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg. 2000;38(4):343–345.
26. Evans D, Land L. Topical negative pressure for treating chronic wounds. Cochrane Database Syst Rev. 2001;(1):CD001898.
27. Evans D, Land L. Topical negative pressure for treating chronic wounds: a systematic review. Br J Plast Surg. 2001;54(3):238–242.
28. Nakayama Y, Iino T, Soeda S.A new method for the dressing of free skin grafts. Plast Reconstr Surg. 1990;86(6):1216–1219.
29. Hynes PJ, Earley MJ, Lawlor D. Split-thickness skin graftsand negative-pressure dressings in the treatment of axillary hidradenitis suppurativa. Br J Plast Surg. 2002;55(6):507–509.
30. 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.
31. Morykwas MJ,Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553–562.
32. Schneider AM, Morykwas MJ,Argenta LC.A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg. 1998;102(4):1195–1198.
33. Chester DL,Waters R.Adverse alteration of wound flora with topical negative-pressure therapy: a case report. Br J Plast Surg. 2002;55(6):510–511.
34. Greer SE, Adelman M, Kasabian A, Galiano RD, Scott R, Longaker MT.The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin. Br J Plast Surg. 2000;53(6):484–487.
35. Guyton AC, Hall JE. The microcirculation and the lymphatic system: capillary fluid exchange, interstitial fluid and lymph flow.Textbook of Medical Physiology. 9th ed. USA: S.B. Saunders Company; 1998:183–197.
36. Simmons EM, Himmelfarb J, Sezer MT, et al.; PICARD Study Group. Plasma cytokine levels predict mortality in patients with acute renal failure. Kidney Int. 2004;65:1357–1365.
37. Beasley RW.The stiffened hand. In: Evarts CM, ed. Surgery of the Musculoskeletal System. Vol 1. New York, NY: Churchill Livingstone; 1983:2:693–706.
38. Jones V, Milton T. When and how to use hydrocolloid dressings. Nurs Times. 2000;96(4 Suppl):5–7.
39. Singh AK, Ray A, Kumar VA. Study on the efficacy of negative pressure application in the management of the pressure ulcers. Indian J Plast Surg. 2000;33:27–29.
40. Mullner T, Mrkonjic L,Kwasny O,Vecsei V.The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997;50(3):194–199.
41. Gabriel A, Heinrich C, Shores JT, Baqai WK, Rogers FR, Gupta S. Reducing bacterial bioburden in infected wounds with vacuum assisted closure and a new silver dressing—a pilot study.WOUNDS. 2006;18(9):245–255.
42. Joseph E, Hamori CA, Bergman S, Roaf E, Swann NF, Anastasi GW.A prospective, randomized trial of vacuumassisted closure versus standard therapy of chronic nonhealing wounds.WOUNDS. 2000;12(3):60–67.
43. McCallon SK, Knight CA, Valiulus JP, Cunningham MW, McCulloch JM, Farinas LP.Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage. 2000;46(8):28–34.
44. Téot L, Otman S, Hussenet P, Moles J. Expression of angiogenic factors in chronic wounds treated with negative pressure therapy. Presented at: the 10th Annual Meeting of the European Tissue Repair Society; May 2000; Brussels, Belgium.
45. Giovannini UM, Demaria RG,Teot L. Interest of negative pressure therapy in the treatment of postoperative sepsis in cardiovascular surgery.WOUNDS. 2001;13(2):82–87.
46. Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost. 2005;94(6):1181–1185.

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