25 Jun 2009General surgery Unit ISeminar Dr. Daniel Maina

Introduction Drains are important in the management of surgical patients .Definition: They are appliances that act as a deliberate channel through which established or potential collection of pus, blood or body fluid egress to allow a gradual collapse and apposition of tissue.

history Their use dates back to Hippocrates[370 BC] where metal tubes, glass tubes as well as bone were used as passive drains. 2nd century AD Celsus used conical drains for abdominal conditions7th century Hannibal used chest drains for war victims Leonard da Vinci observed Capillary attraction in small-bore tubes [basis of all passive methods ] Heaton [1889] discovered air-vent suction or active drains. 1931 first commercial suction drain produced by Chaffin

IDEAL DRAIN

A drain should be firm, not too rigid, so as to remain in its intended placeNot too soft as it may twist or kink or become blocked Smooth Resistant to decomposition or disintegrationWide and patent enough to prevent easy blockage by effluents Non electrolytic, non carcinogenic and non-thrombogenic when used in vascular surgery

CLASSIFICATION (TYPES) OF DRAINS

Basis and FactorTypesMechanismPassiveActiveNatureTubeSheet/flatDispositionOpenClosedLocationInternalExternalPropertyInertIrritant

PASSIVE DRAINS

Passive drains may simply act by means of this capillary action or gravity. Corrugated rubber drain Penrose drain (a very soft rubber tube with gauze wick inside) sump drain (a multiple lumen tube for continuous drainage, irrigation and aspiration).These drains are used when drainage fluid is too viscous to pass through tubular drains

Sheet of corrugated rubber drain

Penrose drain

ACTIVE DRAINS

These are tube drains that are aided by active suction. - Salem sump NG tube (Low continuous suction) -Levin NG tube( Low intermittent suction) - Sump suction for high output fistulae - Redivac, Haemovac, surgivac drains

Salem sump tube

Redivac drain

Jackson-Pratt drain

OPEN DRAINS

- Penrose drain, gauze drains, sheet drain, corrugated rubber drains.

Tube drain (open)

Gauze wick drain

Glove finger drain

CLOSED DRAIN

- Any tube drain such as latex, rubber, silicon drains, Levin NG tube.

Close Tube drain

Close tube (small size) facial/ plastic wounds

FLAT DRAINS

made flat with 3/4 or full length multiple perforations which can be connected to a tubing system. The inner wall of the flat segment usually has internal ribs to prevent it from collapsing or kinking. They are often used for various surgeries, including plastic and reconstructive surgery.

Flat drain

EXTERNAL DRAINS

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.

INTERNAL DRAINS

placed internally within luminal organs to create a route or to connect two luminal organs. divert retained fluid from primary drainage site or area to a distal body to bypass an obstruction. They are used in neurosurgery for internal drainage of hydrocephalusventriculo- jugular shunt, ventriculo-atrial shunt,ventriculo-peritoneal shuntGI surgery where souther tube, Celestine tube and mousseau-barbun tube could be used to palliate malignant obstruction of the esophagus. stents in urethral and ureteric strictures .

INDICATIONS FOR SURGICAL DRAINS

TherapeuticTension pneumothoraxPleural fluidAbscess cavitySeromaAcute urinary retensionAcute suppurative arthritis Infected cyst

Diagnostic Biliary fistulaT-tube cholangiogram for retained gall stones in common bile duct

Prophylactic

Cardiothoracic proceduresEsophageal resectionDuodenal stump following polya gastrectomyElevation of extensive skin flapPost thyroidectomyThoracotomyUncomplicated cholecystectomy SplenectomyPancreatectomy

Monitoring Gastrointestinal bleedingUrethral catheterizations

Palliative Advanced Ca esophagus Hydrocephalus

CARE OF SURGICAL DRAINS

Intra- operativePlaced such that they take the safest, shortest route possible. Should reach the deepest, most dependent part of the cavity or wound. Brought out through a stab wound.Tubing should remain free of kinks, debris and clots.Should be secured well so as to avoid falling off or its migration into the cavity or erosion of surrounding tissue.Drain should be lower than the incision at all times.

Securing a surgical drain Drains have been secured using various techniques and materials Roman Garter technique which uses silk to secure the drain.Use of nylon suture safety pin drain clip adhesives.

The post-operative care of a drain depends on the type, purpose and location of the drain . skin around must be kept clean and dry to prevent infection and skin irritation. Meticulous skin care and aseptic technique must be observed during application and change of dressing over drains.

Post operative care of a surgical drain

Gauze dressings are used around and over drainage tubesto protect the tube absorb some amount of drainage assist with the stabilization of the tube protect from external contamination.An accurate measurement and record keeping of drainage output. Replace fluid loss through drain by additional intravenous fluids. Drain container or reservoir should be emptied at least once a day. Regular activation of the reservoir of active drains must be ensured.

When to discontinue a surgical drain

Once the drainage has stoppedits output has become

COMPLICATIONS

Tissue reaction Source of contamination Delayed return of functionRetained foreign bodyTissue necrosis Bowel herniationHaemorrhage Prolonged healing time Drain entrapment and lossFluid, electrolytes and protein loss Migration of the drainErosion of viscera

CONCLUSION

The use of drain in surgical practice has been contentious over the years.The essential questions a surgeon needs to answer when deciding on the value of surgical drains are: 1. What purpose would a drain serve if placed? 2. What type of drains should be used? 3. 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.

THANK YOU

M.A.ALFALLOUJI; 2nd Edtn, Post graduate surgery.Sabiston,;16th Edtn, Textbook of surgery.Makama J.G;Surgical Drains: What the Resident needs to know.NJM vol.17.no.3 July-August 2008. www.surgical-tutor.com