The use of drains in abdominal surgery can be for either therapeutic or prophylactic reasons. Therapeutic drainage occurs when there is an intra-abdominal collection of pus, gas, or extravasation of other fluids such as bile, gastric secretions, pancreatic juice, urine, or blood. It is successful only in an area where an abscess cavity has been established or when there is a continuous flow of fluid. Prophylactic drainage is
employed after an operative procedure when there is a significant probability of leakage of physiologic fluids and when drainage would be preferable to permitting a collection with the potential for complications. Therapeutic drainage also treats preexisting infection, whereas prophylactic drainage attempts to prevent infection.
The principles for using drains are explicit. Drains should be carefully positioned to evacuate efficiently the site where fluids collect. Drains should take the shortest possible route to the skin surface. To lessen the chance of erosion into adjacent vessels or organs, drains should be meticulously placed. If the original attempt for optimal drainage fails, a short drainage tract will facilitate surgical access by following the course of the drain. The ideal drain should not become a path for the introduction of infection and should be withdrawn as soon as it is no longer needed. As a general policy, drains should not be brought out through the operative incision. The egression of even a Penrose drain through the abdominal incision rather than by an adjacent stab wound has been reported to increase the incidence of infection from 2.4 to 4%. An even more striking increase in wound infection is observed with cholecystectomies. Here the incidence of infection associated with the use of a separate stab incision is 1.8%. When the drain is brought out through the primary incision, the incidence rises to 9.9%.1 •
The materials used to manufacture abdominal drains must possess certain physical and chemical properties. Drains should be soft and pliable and elicit only mild to no tissue reaction. They should be composed of stable materials that will not readily decompose.
All intra-abdominal drains can be described as either passive or active in their attempts at drainage. Historically, the most common passive drain was the latex rubber drain, known as the Penrose or cigarette drain ( Fig. 22-1A ). Other simple drains are shown in Figure 22-1 . The Penrose drain establishes a path of least resistance and provides drainage by overflow of fluid through its lumen. Its drainage is influenced by
position, gravity, small pressure differences, and capillary action. Effective drainage cannot be accomplished by a small stab wound for the exit site of the Penrose drain; one must be able to insert at least one finger through all layers into the intraperitoneal cavity. If the skin incision is not large enough and the drain is readily compressible, it will act as a plug.1 • 1 • There are several modifications of the Penrose drain. The Ragnall drain is made of soft rubber, and its lumen is corrugated ( Fig. 22-2B ). In the United Kingdom, a flat polyvinylchloride drain that is corrugated and multitubular is often used in the place of a Penrose drain ( Fig. 22-2 C ). Both of these drains as well as other similar drains are at least as effective as the Penrose drain. These flat passive drains are advantageous when the material will not flow through tubular drains because it is viscous or filled with large pieces of detritus.
The tube drain is an additional simple method for nonviscid, nonparticulate drainage. It is an overflow drain that functions similarly to the Penrose drain. Often, tube drains tend to be rigid and, if not placed carefully, can erode into adjacent structures. The holes in a tube drain can be occluded by intraperitoneal surfaces, fat, or tissue fragments. Active or suction drains are modifications of tube drains. There are advantages of the suction drain over the passive drainage system. Suction drains can accurately measure drain effluent and the skin surrounding a suction drain site can be protected from a discharge that may cause skin breakdown and secondary infection. The suction
Figure 22-1 Four types of drains for peritoneal drainage. A, Penrose drain. B, Tube drain. C, Sump drain. D, Sump-Penrose drain. (FromHanna, E.A.: Efficiency of peritoneal drainage. Surg. Gynecol. Obstet, 131:983, 1970. By permission of Surgery, Gynecology and Obstetrics.)
Figure 22-2 Four types of passive drains. A, Latex Penrose drain. B, Ragnall soft rubber tube with intraluminal corrugations. C, Corrugated polyvinyl chloride multitubular drain. D, Four-wing latex Malecot catheter (can also be used for suction drainage). (From Dougherty, S.H., and Simmons, R.L.: The biology and practice of surgical drains, parti. Curr. Probl. Surg., 29:570, 1992, with permission.)
Figure 22-3 Two closed suction drainage systems. A, Hemovac polyvinyl chloride drain with collapsible drum reservoir. B, Jackson-Pratt Silastic drain with bulb reservoir. (From Dougherty, S.H., and Simmons, R.L.: The biology and practice of surgical drains, part I. Curr. Probl. Surg., 29:571, 1992, with permission.)
Figure 22-4 Three types of sump drains. A, Waterman. B, Andersen-Shirley. C, Argyle. (From Dougherty, S.H., and Simmons, R.L.: The biology and practice of surgical drains, part II. Curr. Probl. Surg., 29:669, 1992, with permission.)
Figure 22-5 Sump drain construction. A, No. 22 French Foley urethral catheter. B, The balloon tip and inlet seal are cut from the Foley catheter. Holes are also cut on the side of the large-outlet catheter. C, Vaginal or plain gauze packing. D, The sump catheter is completely enclosed in gauze packing. E, The Penrose drain is introduced over the gauze-covered sump. F, A heavy tie fixes the catheter, gauze, and Penrose drain. Holes are cut in the side of the Penrose drain. (From Ransom, J.H. C.: Safer intraperitoneal sump drainage. Surg. Gynecol. Obstet, 137:841, 1973. By permission of Surgery, Gynecology and Obstetrics.)
1. Abramson, D.J.: A new, soft, triple lumen, overflow and suction drain. Am. J. Surg., 120:414, 1970.
2. Baker, M.S., Brochardt, K.A., Baker, B.H., et al.: Sump tube drainage as a source of bacterial contamination. Am. J. Surg., 133:617, 1977.
3. Cruse, P.J., and Foord, R.: A five-year prospective study of 23,649 surgical wounds. Arch Surg., 107:206, 1973.
4. Dougherty, S.H., and Simmons, R.L.: The biology and practice of surgical drains, part I. Curr. Prob. Surg., 29:570, 1992.
5. Dougherty, S.H., and Simmons, R.L.: The biology and practice of surgical drains, part II. Curr. Probl. Surg., 29:669, 1992.
6. Formeister, J.F., and Elias, E.C.: Safe intra-abdominal and efficient wound drainage. Surg. Gynecol. Obstet., 142:415, 1976.
7. Garcia-Rinaldi, R., Defore, W.W., Jr., Green, Z.D., et al.: Improving the efficiency of wound drainage catheters. Am. J. Surg., 130:372, 1975.
8. Hanna, E.A.: Efficiency of peritoneal drainage. Surg. Gynecol. Obstet., 131:983, 1970.
9. Ranson, J.H.C.: Safer intraperitoneal sump drainage. Surg. Gynecol. Obstet., 137:841, 1973.
10. Tanner, N.C.: Use of drains in the peritoneal cavity and abdominal wall. In Cooper, P. (ed.): The Craft of Surgery, 2nd ed. London, J & A Churchill, 1964, pp. 918-927.
11. Waterman, N.G., Walsky, R., Kasdan, M.L., et al.: The treatment of acute hemorrhagic pancreatitis by sump drainage. Surg. Gynecol. Obstet., 126:963, 1968.
Chapter 23 - Complications of Incision
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