Use of drains in surgery: a review.
Abstract: Drains have been used in surgery for several years to remove body fluids thereby preventing the accumulation of serous fluid and improving wound healing. Drains may be classified as closed or open systems, and active or passive depending on their intended function. Closed vacuum drains apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing. Correct assessment of clinical indications might reduce unnecessary usage. This article will introduce the principles and practice of various types of drains and highlight the importance of understanding how surgical drains promote quality patient care.

KEYWORDS Drains / Closed drains / Open drains
Article Type: Report
Subject: Drainage, Surgical (Usage)
Drainage, Surgical (Health aspects)
Wound healing (Health aspects)
Wound healing (Methods)
Authors: Durai, Rajaraman
Mownah, Abdoolla
Ng, Philip C.H.
Pub Date: 06/01/2009
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: June, 2009 Source Volume: 19 Source Issue: 6
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 202438733
Full Text: Introduction

Surgical drains are manufactured tubes that drain various bodily fluids and have been used in surgery for several years. Their application can be broadly classified as prophylactic and therapeutic. Drains have several functions. They remove body fluids thereby preventing the accumulation of serous fluid (seroma), and improving wound healing. Seromas are a good nidus for infection; they can cause discomfort and are alarming for the patient.

Classification

Drains may be classified (Table 1) as closed or open systems, and active or passive depending on their situation and function. A closed drain is one in which the contents are not exposed to the atmosphere and these are further sub classified into vacuum and non vacuum varieties. An open drain communicates with the atmosphere. Closed drains encourage an anaerobic environment which may promote the growth of certain bacteria. An active drain is one which is driven by negative pressure. A passive drain is one that simply channels fluids.

A1 Closed vacuum drainage systems Closed vacuum drainage systems are closed circuit suction drainage systems that are designed to apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing.

Redivac[R]

The Redivac[R] system (Fig 1) is an example of a negative pressure drain with a vacuum that draws the fluids into a reservoir bottle. The drain tube is available in variable sizes, however the bottle is a single, standard size. The drawback of this system is that when the reservoir bottle is full, it needs to be replaced. The clear reservoir allows measurement of daily output but is prone to breakage if dropped. The presence of a vacuum can be seen from the outside from the retracted green rubber portion. When there is loss of vacuum but the bottle is empty, the vacuum can be recreated by attaching the bottle to a suction machine. When the drain needs to be removed, the vacuum should be released first, otherwise it can cause pain from the negative pressure holding the tissues (Schein 2008). The rate of haematoma and seroma formation after face lift surgery decreased significantly after using vacuum drains during the first 24 hours (Perkins et al 1997).

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Jackson-Pratt[R] drain

The Jackson-Pratt drain has a soft, pliable, silicone tube with multiple perforations along the side and there is a bulb that can be used to recreate the low negative pressure vacuum, which also collects fluid. As a low negative pressure suction system, it is designed so that intra abdominal contents such as the omentum or intestines are not sucked into the tube, minimising the risk of bowel perforation or ischaemia.

J-Vac[R] drain

The J-Vac[R] drain is another form of low negative pressure system. It has a silicone tube with grooves at the body cavity end which form four tiny lumens. These join to form a single lumen at the reservoir end. Its main advantages are: it does not get blocked easily by omentum, the vacuum can be recreated at the reservoir without having to change the reservoir, and the silicone material is less painful for the patient.

Vacuum assisted closure (VAC[R]) devices VAC[R] devices are used for the closure of open wounds including limbs (figure 2), the chest and the abdomen. Abdominal VAC[R] dressings are used when primary closure of a laparotomy wound is impossible because of increased pressure in the abdomen, or when a relook laparotomy may be needed in gross abdominal sepsis. The abdominal viscera are protected by a porous non-adherent film on the top of which a sponge and polyfilms are applied. A vacuum pad can be applied to create a negative pressure. Abdominal VAC[R] drains have transformed the management of the septic abdomen and do not need to be replaced for 48 hours. Figure 2 shows an example of vacuum assisted wound dressing applied to the foot wound. Even though VAC[R] dressings are a form of wound dressing, they act like surface drains rather than cavity drains and therefore included under vacuum drains.

A2 Closed non-vacuum drains Robinson drainage system

Wallace silicone drainage tubes are used in this system (Fig 3). They have holes on the sides of the inner end. They are the most commonly used closed passive drainage system.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

Mallecot drain

The Mallecot drain is a red rubber tube drain with a self-retaining mushroomed end, which is intended to cause fibrotic tissue formation around it. It is useful whenever a tract needs to be created. It can also be used for open suprapubic cystostomies. The drain is outdated and silicone drains are used now because of possible latex allergy.

Pigtails

Pigtails are small lumen self-retaining drains, curled in the shape of a pigtail which are used for draining a single cavity (Fig 4). They are mostly used by radiologists for ultrasound-guided or CT guided drainage but are not useful in septated cavities or when the pus is thick. Their patency can be maintained by flushing them once or twice every day as they are passive drains that get blocked easily. Their removal requires the cutting of a thread to unwind the self retaining end before the drain can be pulled out.

Chest tube drains

A chest tube drain (Fig 5) is a passive drain similar to a Wallace drain but attached to an underwater seal to provide a non-return valve. The consistency of the tube is stiff so it does not collapse easily but this causes a lot of discomfort and is poorly tolerated. The tube needs to be clamped during patient transport. Suction can be applied to convert a chest tube drain into an active drain.

'T' tube drains

These drains in the shape of a 'T' are used after exploration of the common bile duct. The duct is closed on the drain, and the long part of the drain is brought out through the abdominal wall to form a controlled external biliary fistula. A cholangiogram can be performed via this tube to assess the patency of the bile duct and to exclude any bile duct stones. The drain can be clamped at seven days and if there are no signs of biliary obstruction, it can be pulled out. The fistula will close by itself provided there is no distal obstruction in the bile duct.

B Open drains

Corrugated drain

The corrugated drain comes in the shape of a red rubber corrugated sheet. This is now replaced by silicone. The drain sheet can be cut to the required size. It does not get blocked easily. These drains may connect the atmosphere and the inside of the wound and therefore may introduce infection into the wound. Corrugated drains are often used in the treatment of diabetic foot abscesses (Lawes & Refson 2004). A stoma bag can be applied around the drain site to collect the drain contents so that it will not soil the patient's clothes and bed, allowing measurement at the same time. Usually a safety pin is attached to the drain to prevent it from migrating into the wound.

Penrose drain

A Penrose drain is a flat rubber ribbon-like drain. A gauze dressing is applied around the external end of the Penrose drain to absorb the drainage fluid, which may otherwise leak. The volume of drainage fluid can be roughly estimated by weighing the gauze swabs. Bacteria can enter and colonise the wound because this drain is exposed to the atmosphere. Often the drain is left only for a few days to drain pus. Therefore the bacterial colonisation is not an issue in practice.

Sump drain

A Sump drain consists of a smaller inner tube and a larger outer, perforated tube. It is used for irrigation particularly in conditions like necrotizing pancreatitis. Suction is applied to the smaller inner tube and it allows the drain to remain patent.

Diagnostic peritoneal drains

Peritoneal drains or diagnostic insertion of umbilical vein catheter transperitoneally may help to diagnose conditions such a hollow viscus perforation and haemorrhagic ascites. They are particularly useful in resuscitating small critically ill infants with necrotising enterocolitis (Ahmed et al 1998).

Drain fixation

The drains are usually fixed to the skin by means of sutures, which are usually silk. The exemptions are the radiologically-inserted drain, and Penrose drains. Pigtail drains are self-retaining. A safety pin can be used to prevent migration of the drain into the wound.

Drain removal

Although there is no scientific evidence available, a generally accepted rule is that if a drain produces less than 25ml in the previous 24 hours (approximately 1ml/hr), then it is safe to remove.

Complications

Drains are not without complications. They can cause haemorrhage, tissue inflammation, retrograde bacterial migration and drain entrapment (Walker 2007). Drains sometimes break during their removal, leaving a drain fragment in the wound (Hak 2000). Abdominal silicone drains may cause pressure necrosis and can lead to bowel perforation (Nomura et al 1998). After prolonged use, a drain can erode the bowel and may lead to an enterocutaneous fistula. Suction drains may increase the risk of postoperative infectious complications (Ghezzi et al 2003). Use of drains may prolong the hospital stay and therefore result in increased cost of treatment (Alvarez Uslar et al 2005).

Contraindications

A drain should not be inserted in to a haematoma with an underlying arterial anastomosis, because the patient may become hypotensive from depletion of blood volume.

In certain cases a drain is not routinely necessary (Table 2).

Discussion

Drains are used in a variety of clinical situations. Drain sites are often painful and it is useful to inject local anaesthetic around the drain site both prior to their insertion and prior to their removal (Yiannakopoulos & Kanellopoulos 2004). Usually the amount of drainage that is collected in the drain reservoir is maximal in the first 24 hours. Sometimes the reservoir can be full and the patient can develop a haematoma from the residual collection. Drain bottles should be monitored frequently for the first 24 hours after insertion (Williams et al 2003).

Surgical examples

Abdominal drains

Sump drains are often used after pancreatic necrosectomy (Branum et al 1998). If the pancreatic drainage fluid shows an amylase >5000U on the first post-operative day, it indicates a potential pancreatic fistula (Molinari et al 2007). Early drain removal within four days after a Whipples operation reduces intra-abdominal infections(Kawai et al 2006). Subcutaneous drainage in obese patients may reduce seroma development after cholecystectomy (Chowdri et al 2007). After laparoscopic cholecystectomy, trocar insertion sites may be used for inserting the drains (Komuta et al 2000). Drains inserted after laparoscopic Roux-en-Y gastric bypass are helpful in detecting anastomotic leaks (Chousleb et al 2004) because one can see small bowel contents in the drain. Abdominal drain sites are often colonised with enterococcus and coagulase negative Staphylococci which are resistant to meticillin (Michalska et al 1997). A drain is not essential after low rectal anastomosis (Brown et al 2001).

Thyroid surgery

Drains are not essential after uncomplicated thyroid surgery (Talmi 2004). Drains prolong the hospital stay, increases the risk of infection and treatment costs (Suslu et al 2006, Lee et al 2006). Haematomas still occur with drains in situ (Karayacin et al 1997).

Orthopaedic surgery

Neither the insertion of drainage nor clamping alter the transfusion rates after knee replacement (Sundaram & Parkinson 2007, Kiely et al 2001). Transfusion requirements are increased in hip arthroplasty after using drains (Walmsley et al 2005, Widman et al 2002). Drains decrease the incidence of epidural hematoma on the first postoperative day after lumbar disc surgery (Mirzai et al 2006).

Breast surgery

Seromas are common after breast and axillary surgery, often requiring needle aspiration (Soon et al 2005). When inserted, drains may be safely removed on the second postoperative day (Yii et al 1995) although there is an increase in the occurrence of seromas requiring further treatment (Barton et al 2006). The use of a buttress suture may reduce the seroma rate after axillary clearance (Schuijtvlot et al 2002). It is beneficial to use drains both in the breast and abdomen after breast reconstruction using the TRAM flap (Scevola et al 2002).

Chest drain

The most common error made while inserting a chest drain is choosing a site which is too low--far down below the safe triangle which is bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, and a line superior to the horizontal level of the nipple (Griffiths & Roberts 2005). A chest drain should be monitored by assessing the swinging of the water column and air bubbling. If there is no swinging, it means the chest may be expanded fully or the tube may be blocked. A chest X-ray will demonstrate any residual pleural fluid, pneumothorax and status of expansion of the lung. The drain should be clamped when changing the underwater seal bottle.

How do the drains affect the patient?

Having a drain may cause inconvenience to the patient. It may delay the patient's discharge until it is removed. Drain sites can be very painful. It may be difficult for the patient to sleep comfortably with a drain which can be get caught and inadvertently pulled out. In the long-term, the drain site may leave a puckered scar which may be unsightly because it may be left to close by natural healing.

Summary

Knowing the function and the current best available evidence for using the drains may reduce unnecessary insertions. The drains are used for both prophylactic and therapeutic purposes. Each drain has a specific use. An active drain is one which is driven by negative pressure. A passive drain is one that simply channels fluids. Whilst removing a drain, negative pressure, if present, should be released first otherwise it may cause pain. Redivac[R] is a commonly used vacuum drain. J-Vac[R] is a special kind of vacuum dressing where the vacuum can be recreated by adjusting the reservoir. Chest drains are attached to an underwater seal and suction can be applied if there is an air leak. Corrugated drains may introduce bacteria into the wound and are used in diabetic foot abscesses. Pigtails are radiologically inserted and Penrose drains are flat rubber like and are very rarely used. Drains can cause bleeding, inflammation and can break during their removal. A good understanding of how various types of drains work will help to monitor their function and contribute to better care of drains and the patient.

Task 1

Explore your theatre stock room to look at various drains, their sizes and find out which ones are active and which ones are passive drains.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 4: Service improvement HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

Task 2

See various patients with drains and find out the indications for the placement of drains and how they affect the patient.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 4: Service improvement HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

Task 3

Look at J-Vac[R] and Redivac[R]. Try to familiarise yourself with how to reproduce the vacuum

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 4: Service improvement Core 5: Quality

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

Task 4

Review the indications for various drains and their complications

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 4: Service improvement

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

Task 5

A patient has a chest drain. How will you monitor a chest drain and what are the precautions that are required while transporting such a patient?

* Examine the dressing around the drain and observe for signs of leakage.

* Monitor the skin around the drain, is it excoriated, irritated, erythematous ? What can be used to prevent skin damage around drains.

* At each change of dressing the retaining stitch is checked to see if the drain is still securely fastened.

* Monitor the characteristics of the drainage: Rate, volume per shift or 24 hours, quality, colour, presence of blood and report accordingly.

* Does a sample need to be sent to determine the nature of the drainage? Some drains may require the application of a collecting/ stoma bag around the site to allow accurate measurement.

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 4: Service improvement

HWB6: Assessment and treatment planning

Additional Learning Resources Associated AfPP online modules:

* Skin Preparation

* Infection Control

* Universal / Standard Precautions * Patient Care in the Operating Department

Reflective model

You will find several reflective module templates for you to utilise when utilising reflective practice for your CPD under the career development tab on the AfPP web site.

Provenance and Peer review: Unsolicited contribution; Peer reviewed.

References

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Aldameh A, McCall JL, Koea JB 2005 Is routine placement of surgical drains necessary after elective hepatectomy? Results from a single institution Journal of Gastrointestinal Surgery (9) 667-71

Alvarez Uslar R, Molina H, Torres O, Cancino A 2005 Total gastrectomy with or without abdominal drains. A prospective randomized trial Revista Espanola de Enfermedades Digestivas (97) 562-9

Barton A, Blitz M, Callahan D, Yakimets W, Adams D, Dabbs K 2006 Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial American Journal of Surgery (191) 652-6

Branum G, Galloway J, Hirchowitz W, Fendley M, Hunter J 1998 Pancreatic necrosis: results of necrosectomy, packing, and ultimate closure over drains Annals of Surgery (227) 870-7

Brown SR, Seow-Choen F, Eu KW, Heah SM, Tang CL 2001 A prospective randomised study of drains in infra-peritoneal rectal anastomoses Techniques in Coloproctology (5) 89-92

Chousleb E, Szomstein S, Podkameni D, Soto F, Lomenzo E et al R 2004 Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients Obesity Surgery (14) 1203-7

Chowdri NA, Qadri SA, Parray FQ, Gagloo MA 2007 Role of subcutaneous drains in obese patients undergoing elective cholecystectomy International Journal of Surgery 5 (6) 404-407

Dallal RM, Bailey L, Nahmias N 2007 Back to basics--clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary Surgical Endoscopy 21 (12) 2268-2271

Erdem E, Sungurtekin U, Nessar M 1998 Are postoperative drains necessary with the Limberg flap for treatment of pilonidal sinus? Diseases of Colon and Rectum (41) 1427-31

Ghezzi F, Franchi M, Buttarelli M, Serati M, Raio L, Maddalena F 2003 The use of suction drains at burch colposuspension and postoperative infectious morbidity Archives of Gynecology and Obstetrics (268) 41-4

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Gurusamy KS, Samraj K 2007 Wound drains after incisional hernia repair Cochrane Database of Systematic Reviews CD005570

Hak DJ 2000 Retained broken wound drains: a preventable complication Journal of Orthopaedic Trauma (14) 212-3

Karayacin K, Besim H, Ercan F, Hamamci O, Korkmaz A 1997 Thyroidectomy with and without drains East African Medical Journal (74) 431-2

Kawai M, Tani M, Terasawa H, Ina S, Hirono S et al 2006 Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients Annals of Surgery (244) 1-7

Kiely N, Hockings M, Gambhir A 2001 Does temporary clamping of drains following knee arthroplasty reduce blood loss? A randomised controlled trial Knee 8 (4) 325-7

Kim J, Lee J, Hyung WJ, Cheong JH, Chen J, Choi SH, Noh SH 2004 Gastric cancer surgery without drains: a prospective randomized trial Journal of Gastrointestinal Surgery 8 (6) 727-32

Komuta K, Haraguchi M, Inoue K, Furui J, Kanematsu T 2000 Herniation of the small bowel through the port site following removal of drains during laparoscopic surgery Digestive Surgery 17 (5) 544-6

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Kumar S, Penematsa S, Parekh S 2006 Are drains required following a routine primary total joint arthroplasty? International Orthopaedics 31 (5) 593-596

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Lee SW, Choi EC, Lee YM, Lee JY, Kim SC, Koh YW 2006 Is lack of placement of drains after thyroidectomy with central neck dissection safe? A prospective, randomized study Laryngoscope 116 (9) 1632-5

Michalska W, Chylak J, Marciniak R, Lange M, Drews M 1997 Analysis of aerobic and anaerobic bacterial flora colonizing drains after surgical abdominal incisions Medycyna Dowiadczalna i Mikrobiologia 49 (1-2) 75-81

Mirzai H, Eminoglu M, Orguc S 2006 Are drains useful for lumbar disc surgery? A prospective, randomized clinical study Journal of Spinal Disorders and Techniques 19 (3) 171-7

Molinari E, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G, Falconi M, Pederzoli P 2007 Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients Annals of Surgery 246 (2) 281-7

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Scevola S, Youssef A, Kroll SS, Langstein H 2002 Drains and seromas in TRAM flap breast reconstruction Annals of Plastic Surgery 48 (5) 511-4

Schein M 2008 To drain or not to drain? The role of drainage in the contaminated and infected abdomen: an international and personal perspective World Journal of Surgery 32 (2) 312-21

Schuijtvlot M, Sahu AK, Cawthorn SJ 2002 A prospective audit of the use of a buttress suture to reduce seroma formation following axillary node dissection without drains Breast 11 (1) 94-6

Soon PS, Clark J, Magarey CJ 2005 Seroma formation after axillary lymphadenectomy with and without the use of drains Breast 14 (2) 103-7

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Correspondence address: R Durai MD MRCS, Department of Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH. E-mail : dr_durai@yahoo.com

About the authors

Rajaraman Durai

MD MRCS

Specialist Registrar, Department of Surgery,

University Hospital Lewisham, London

Abdoolla Mownah

MD FRCS

Consultant Surgeon, Noble's Hospital, Isle of Man

Philip C H Ng

MD FRCS

Consultant Surgeon, Department of Surgery,

University Hospital Lewisham, London
Indications for the use
of a drain

Prophylactic

1) To remove excess blood and serum
2) To remove pus, blood, serous exudates,
chyle or bile
3) To form a controlled fistula e.g. after
common bile duct exploration

Therapeutic

1) To drain pus, blood, serous exudates,
chyle or bile
2) To drain air from the pleural cavity
3) To drain ascites


A) Closed drains

1 Vacuum drains
Vacuum drainage system (Redivac[R],
J-Vac[R], abdominal VAC[R] drains)
Vacuum assisted closure device (VAC[R])

2 Non-vacuum drains
Robinson drain
Mallecot
Pigtail drain
Chest tube drains with an underwater
seal
T-tube drain

B) Open drains

Corrugated drain
Penrose drain
Sump drain


Table 1 Classification of various drains

Type         Examples of Closed Drains   Examples of Open Drains

Vacuum       Redivac[R]                  Not applicable
             J-Vac[R]
             Abdominal VAC[R] drains
             Vacuum assisted closure
             dressing

Non-Vacuum   Robinson drain              Corrugated drain
             Pigtail drains              Sump drain
             Mallecot                    Penrose drain
             Chest tube drains
             T tube drain

Table 2: Studies suggesting that routine use of a drain is unnecessary

Reference            Surgery type               Comments

Erdem et al 1998     Limberg flaps for          No drains will result
                     pilonidal abscess          in shorter stays

Tander et al 2003    Uncomplicated perforated   Drains are not
                     appendicitis               indicated

Kim et al 2004       Gastric cancer surgery     Prophylactic drain
                     with extended lymph node   placement does not
                     dissection                 offer additional
                                                benefit

Aldameh et al 2005   Elective hepatectomy       Routine use of suction
                     is not necessary           drains

Pothier 2005         Thyroid and parathyroid    Routine use of suction
                     surgery is not essential   drains

Kumar et al 2006)    Uncomplicated total        Routine use of suction
                     joint arthroplasty is      drain
                     unnecessary

Gurusamy & Samraj    Incisional hernia repair   There is no evidence to
2007                                            recommend the use
                                                drains
Kumar et al 2007,    Gastrectomy and gastric    Routine drainage is not
Dallal et al 2007    bypass                     necessary
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