SURGICAL DRAINS

25 Jun 2009 General surgery Unit I Seminar

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 conditions 7th 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 place

Not too soft as it may twist or kink or become blocked

Smooth

Resistant to decomposition or disintegration

Wide and patent enough to prevent easy blockage by effluents

Non electrolytic, non carcinogenic and nonthrombogenic when used in vascular surgery

CLASSIFICATION (TYPES) OF DRAINS

Basis and Factor
Mechanism Nature Disposition Location Property Passive Tube Open Internal Inert

Types
Active Sheet/flat Closed External Irritant

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 hydrocephalus
ventriculo- jugular shunt, ventriculo-atrial shunt, ventriculo-peritoneal shunt

GI 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

Therapeutic Tension pneumothorax Pleural fluid Abscess cavity Seroma Acute urinary retension Acute suppurative arthritis Infected cyst

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

Prophylactic

Cardiothoracic procedures Esophageal resection Duodenal stump following polya gastrectomy Elevation of extensive skin flap Post thyroidectomy Thoracotomy Uncomplicated cholecystectomy Splenectomy Pancreatectomy

Monitoring Gastrointestinal bleeding Urethral catheterizations

Palliative Advanced Ca esophagus Hydrocephalus

CARE OF SURGICAL DRAINS

Intra- operative
Placed 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.

Post operative care of a surgical drain

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.

 Gauze dressings are used around and over drainage tubes

to 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 stopped its output has become <25-50ml/day the drain has stopped serving the desired function. The character and viscosity of the drainage fluid are occasionally considered before drains are removed such as an initial haemorrhagic effluent becoming clear fluid. Some drains, particularly open (passive) e.g. corrugated or flat should be shortened 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.

COMPLICATIONS

Tissue reaction Source of contamination Delayed return of function Retained foreign body Tissue necrosis Bowel herniation Haemorrhage Prolonged healing time Drain entrapment and loss Fluid, electrolytes and protein loss Migration of the drain Erosion 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.
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