surgical drains - lms.su.edu.pk
TRANSCRIPT
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Surgical Drains
Prof. Naveed Jabbar Bandesha
Chairman Department of Surgery & Allied
SMC/UOS
Sargodha
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Introduction
• Drains remove content of body organs, secretion of body cavities and other fluids
• Deliberate channels
• Use with prudence as useful & dangerous
• Use dates back to Hippocrates
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Mechanism of Drain
• A Drain removes
• Contents of body as urine
• Excess secretions of body as in peritoneal & pleural cavities
• Tissues fluids as blood ,lymph
• Achieved by gravitational force or negative or positive pressures
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Mechanism of Drain
• • Efficacy of drain depends on
• Diameter , length
• Viscosity & consistency of fluid
• Force which could be +ve or –Vepressure
If fluid accumulates
P on surgical site & adjacent organs,
nerves, BV
Pain, Decreased perfusion
Impaired wound healing
Fluid also serves good medium for bacteria growth
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Classification of Drains
Basis or Factor Types
Mechanism Passive Active
Nature Tube Sheet/ Flat
Disposition Open Closed
Location Internal External
property Inert Irritant
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Passive Drains
• Act by the mechanism of capillary action, gravity or the fluctuation of intra-cavity pressure
• Used when drainage fluid is too viscous to pass through tubular drains
• Corrugated Rubber drain
• Penrose drain
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Active Drains
• Aided by active suction
• Can be
• Low continuous
• Low intermittent
• Or
• High suction
• Advantage are
• Reliable measurement of effluent
• Low risk of infection
• Minimal tissue trauma
• No skin excoriation
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Examples of Active Drains
• Jackson-Pratt drain
• Surgivac drain
• Redivac drain
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Difference Between Active & Passive Drains
Active Passive
Function Work by active suction Depends on pressure difference
Pressure Gradient Negative pressure Positive pressure
Drain exit site Dependent position not necessary
Dependent positon necessary for best function
Drain site dressing Minimal or not needed Bulky to absorb fluid output
Measurement of effluent Reliable & accurate Difficult to quantify
Fluid re-collection Unlikely beacusenegativepressure improves tissue apposition
Likely because minimal effect on dead space
Retrograde studies Lower incidence especially with close suction sysytem
High incidence especially with open system
Obstruction of drain More common due to smaller diameter
Less common
Radiographic studies Easy to perform Difficult except in special circumstances like T-tube & NG tube
Pressure necrosis High incidence Low incidence
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Tube Drains
• Hollow tubes of varying materials
• Brought out through body orifice or stab wound
• If connected to bag means closed drain
• If left alone means open drain
• Multiple holes necessary in case one hole becomes blocked
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Sheet Drains
• Made up of sheet of gutters or parallel tubes through which fluid passes
• Corrugated drain
• Yeates drain
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Flat Drains
• Made flat with ¾ or full length multiple perforations which can be connected to tubing system
• So convert it to close system or left opened
• Inner wall of flat segment has internal rib to prevent it from collapsing or kinking
• Used many surgeries like plastic
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Open Drains
• Empty directly to exterior into wound dressing or stoma bag
• Corrugated rubber drain, Penrose, gauze wick drain and glove finger drain are examples
• Used mostly in superficial wound & cavities
• Drained fluid collects in gauze pad or stoma bag
• Difficult to measure quantity
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Open Drains
• High rate of wound infection
• Trauma to the skin from repeated changing of dressing
• Skin excoriation and erythema due to irritation
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External Drains
• These are drains that are brought out through the body wall to the exterior
• The fluid discharge is channeled from the deepest part of the cavity to the exterior.
• This can be passive or active drain.
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Internal Drains
• These are drains that are placed internally within luminal organs to create a route or to connect two luminal organs
• Divert fluid from primary drainage site to distal body passage in order to overcome obstruction
• Used in
Neurosurgery
GI surgery
Malignant obstruction
Stent is an example
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Irritant Drains
• Made of materials that are irritative to the tissue
• Leads to fibrosis & track formation
• Examples are
• Latex drains
• plastic drains
• Rubber drains
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Inert Drains
• These drains are non-irritative to the tissue
• Do not provoke tissue fibrosis
• Examples include
• Solyvinyl chloride (PVC) drains
• Silastic drains
• Silicone drains
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Ideal Drains
• Should be firm
• Should not be soft
• Smooth so not to allow fibrin to adhere
• Should be easily removable after use
• Material should be resistant to decomposition or disinfection
• Non electrolytic
• Non carcinogenic
• Non throbogenic
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The Purpose of a Drain
• Therapeutic
• Palliation
• Prophylactic
• Monitoring
• Access route
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Indications for Surgical Drains Therapeutic
• Tension pneumothorax
• Pleural fluid
• Abscess cavity Seroma
• Acute urinary retension
• Acute suppurative arthritis
• Infected cyst
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Indications for Surgical Drains Palliative
• Advanced Ca esophagus • Hydrocephalus
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Indications for Surgical Drains Diagnostic
• Biliary fistula
• T-tube cholangiogram for retained gall stones in common bile duct
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Prophylactic Drains
• Cardiothoracic procedures
• Esophageal resection
• Duodenal stump following polyagastrectomy
• Elevation of extensive skin flap
• Post thyroidectomy Thoracotomy
• Uncomplicated cholecystectomy
• Splenectomy
• Pancreatectomy
• Patient on PPV post chest trauma
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Monitoring Drains
• Gastrointestinal bleeding
• Urethral catheterizations
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Dual indications (diagnostic + therapeutic) Drains
• Biliary fistula
• Gastrointestinal
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Care of Surgical Drains
• safest shortest route
• Must reach deepest, most dependent part of cavity
• Bring out drain from stab wound & not from main wound
• No kink in drain
• Secure drain well
• Drain must be lower than incision all the times
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Securing a surgical drain
• Need to secured
• System to prevent dislodgement
• Secured by various techniques
• Commonest is Roman Garter Technique
• Other techniques use
• Nylon suture safety pin, drain clip adhesive, Tie-lok
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Post operative care of a surgical drain
• Skin around drainneed to clean,dry to prevent infection & irritation
• Meticulous skin care
• Aseptic technique
• Gauze dressing normally used
• Drain must be inexpensive
• Must be easy to apply & removed without dislodgement
• keep Output record
• Drain container or reservoir should be emptied at least once a day.
• Regular activation of the reservoir of active drains must be ensured
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When to discontinue a surgical drain
• Remove when drainage stopped or output less than 25-50 ml/day, drain has stopped serving the desired function
• Shortening by withdrawing approximately 2cm/day thus allowing gradual healing of the site from it deepest part outwardly
• Drains that were intended to protect postoperative sites, anastomotic sites and require forming a tract should be delayed and removed when intended desire is achieved
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Complications
• Tissue reaction
• source of contamination
• Delayed return of function
• Retained foreign body
• Bowel herniation
• Haemorrahage
• Plongrd healing time
• Drain entrapment & loss
• Fluid, electrolytes and protein loss
• Migration of the drain
• Erosion of viscera
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Controversies
• In favour
• Remove accumulated fluid
• Early detection of leak, bleeding
• Against
• Risk of infection
• Increase hospital stay
• Delay tissue healing
• Causes tissue damage
• Induce anastomotic leak
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Recent Advances
• One way entry valve
• Bottom drainage ports placed at the opposite end of the reservoir from entrance port
• Soft, supple and low profile drain
• Multiple sump lumens to create high internal flow rates
• Dual lumen
• Rotating garment clips
• Variable sizes
• Anti-thrombogenic coating of drain
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Conclusion
• What purpose would a drain serve if placed
• What type of drains should be used
• How long should the drain be left in place?
• Once these questions are carefully and adequately answered each time a drain is used, the effectiveness and advantages can be maximized with minimal problems.