Drainage system in abdominal surgeryPresentation Transcript
Drainage system in abdominal surgery A. Thangamani ramalingam PT, MSc (PSY), MIAP
Drains & tubes
A surgical drain is a tube used to remove pus, blood or other fluids from a wound.
A drainage tube is usually only used in extreme medical situations when the patient is at greater risk of having complications from a collection of fluid around an organ, over the risk of inserting a drainage tube.
used for short periods
To reduce the risk of haematoma formation and break down of wound
an excessive amount of blood and fluid that collects in the cavities of the body, and around organs
faster wound healing or prevent infection
Presence of a drain increases the risk of infection
Damage may be caused by mechanical pressure or suction
Drains may induce an anastomotic leak
Most drains abdominal drains infective within 24 hours
Septic wounds should be drained
Aseptic wounds those having oozing vessels or large area
Wounds with chances of more fluid collection inside
Leaking wounds from anastomosis
Unless there is a definite reason, the drainage should be removed with in 48 hrs
Types of Drainage Tubes
Open or closed
Active or passive
Include corrugated rubber or plastic sheets
Drain fluid collects in gauze pad or stoma bag
They increase the risk of infection
Consist of tubes draining into a bag or bottle
They include chest and abdominal drains
The risk of infection is reduced
Active drains are maintained under suction
They can be under low or high pressure
Passive drains have no suction
Function by the differential pressure between body cavities and the exterior
Types of drainage systems
T he closed drainage system is a system of tubing or other apparatus that is attached to the body to remove fluids in an airtight circuit that prevents any type of environmental contaminants from entering the wound or area being drained.
The open drainage system is a tube or apparatus that is inserted into the body and drains out onto a dressing.
Lastly the suction drainage system uses a pump or mechanical device to help pull the excessive fluid from the body.
Jackson-Pratt drain- closed drainage system / uses suction
consists of a tube connected to a see-through collection bulb. The bulb has a drainage port which can be opened to remove fluid or air so that the bulb can be squeezed to create suction. The drain is placed below the area of the wound.
Penrose drain-open drainage
A Penrose drain is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid.
It is named for the American gynecologist Charles Bingham Penrose (1862–1925)
Redivac drain/Hemovac drain is a closed/suction drainage system
Pigtail drain - has an exterior screw to release the internal "pigtail" before it can be removed
T-Tube drain is used for mostly for patients who have undergone gallbladder surgery or surgery of the surrounding tubes draining the gallbladder. This type of drainage most resembles a T and drains into a collection bag.
Following abdominal surgery gastointestinal motility is reduced for a variable period of time
Gastrointestinal secretions accumulate in stoma and proximal small bowel
May result in:
Postoperative distension and vomiting
Little clinical evidence is available to support the routine use of nasogastric tubes
May increase the risk of pulmonary complications
Of proven value for gastrointestinal decompression in intestinal obstruction
Tubes are usually left on free drainage
Can be also aspirated maybe every 4 hours
Can be removed when volume of nasogastric aspirate is reduced
To maintain electrolyte balance
To ensure nutrition and hydration
A urinary catheter is a form of drain
Commonly used to:
Alleviate or prevent urinary retention
Monitor urine output
Can be inserted transurethrally or suprapubically
The material from which they are made (latex, plastic, silastic, teflon-coated)
The length of the catheter (38 cm 'male' or '22 cm 'female')
The diameter of the catheter (10 Fr to 24 Fr)
The number of channels (two or three)
The size of the balloon ( 5ml to 30 ml)
The shape of the tip
Failure of balloon to deflate
Abdominal incisions are based on anatomical principles
They must allow adequate assess to the abdomen
They should be capable of being extended if required
Ideally muscle fibers should be split rather than cut
Nerves should not be divided
The rectus muscle has a segmental nerve supply
It can be cut transversely without weakening a denervated segment
Above the umbilicus tendinous intersections prevent retraction of the muscle
Midline incisions are the commonest approach to the abdomen
The following structures are divided:
The incision can be extended by cutting through or around the umbilicus
Above the umbilicus the Falciform ligament should be avoided
The bladder can be accessed via an extraperitoneal approach through the space of Retzius
The wound can be closed using a mass closure technique
The most popular sutures are either non-absorbable or absorbable monofilaments
At least 1 cm bits should be taken 1 cm apart
Requires the use of one or more sutures four times the wound length
• A paramedian incision is made parallel to and approximately 3 cm from the midline
• The incision transverse:
o Anterior rectus sheath
o Rectus - retracted laterally
o Posterior rectus sheath - above the arcuate line
o Transversalis fascia
o Extraperitoneal fat
• The potential advantages of this incision are:
o The rectus muscle is not divided
o The incisions in the anterior and posterior rectus sheath are separated by muscle
• The incision is closed in layers
• Takes longer to make and close
• Had a lower incidence of incisional hernia (when sutures were not so good )
Closure of incision
Ambroise Paré (1520-1590)
Paré was an astute observer and brought many innovations to surgery and wound care. One of the most important concepts he introduced was that wounds should be treated gently to reduce inflammation and promote healing. For a significant part of his career Ambroise Paré was a barber surgeon in the army of the king of France. He abandoned the traditional treatment of cauterizing wound after his experience in the battle of Turin in 1536, when the French fought the Italians.
Ligature and suture materials
1. Catgut plain – used to suture mucous membrane of lips, tongues superficial laceration of the genital area. They are easily absorbed within one week.
2. Catgut chromic – used to suture fascia, muscles, or ligature of blood vessels.It is usually absorbed within 30 – 45 days
3. vicryl – same as above. Takes at least 70 days for absorption. Rapid vicryl is easily absorbed.
4. PDS – expensive, takes at least 5 – 6 months to be absorbed.
Absorbable suture materials are those that are broken down. The original absorbable suture materials were plain and chromic “cat gut,” which actually consisted of processed collagen derived from the submucosa of animal intestines. Plain gut is broken down enzymatically after about 7 days. Chromic gut is collagen treated with chromium salts to delay break down. Chromic gut typically loses its strength after 2-3 weeks is completely digested after about 3 months.
Now there are many synthetic absorbable materials made from polymers (e.g., Vicryl and Monocryl). These materials are broken down non-enzymatically by hydrolysis; water penetrates the suture filaments and causes breakdown of the polymer chain. As a result, synthetic absorbables tend to evoke less tissue reaction than plain or chromic gut.
1. Ethilon – most commonly used to close and suture skin after surgery or trauma to the skin. Cutting needles are usually used.
2. Prolene – used to suture nerve, tendon or blood vessels. Preferable round body needles are used.
3. Silk and Linen – have similar properties. They are very strong, but they are adherent to the tissues and can caused reaction or infection.
Non-absorbable sutures are made of materials that are not readily broken down by the body’s enzymes or by hydrolysis. There are naturally occurring non-absorbable materials e.g., silk, cotton, and steel)
synthetic non-absorbable materials (e.g., nylon and Prolene, Mersilene). In some cases they are left in place indefinitely (e.g., when used to close the abdominal fascia), and in other cases they are removed after adequate healing has occurred (e.g., nylon sutures to close a superficial laceration).
Other suture materials
1. Staples – to close wound under high tension, like scalp, trunk and extremities.
2. Strips and tapes – used to close superficial laceration on the face.
3. Derma bond – very expensive, ideal for simple laceration, but fact around the edges have to be removed.
Types of sutures/ METHODS OF SUTURING
Simple interrupted suture
Needles may also be classified by their point geometry; examples include:
taper (needle body is round and tapers smoothly to a point)
cutting (needle body is triangular and has a sharpened cutting edge on the inside)
reverse cutting (cutting edge on the outside)
trocar point or taper cut (needle body is round and tapered, but ends in a small triangular cutting point)
blunt points for sewing friable tissues
side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery
Types of knots
4Rosebud stopper knot
5Matthew Walker's knot
7Turks head knot
8Overhand knot Figure-of-eight knot
9Reef knot Square knot
10Two half hitches
sutures are normally removed after
Face and head ……………. 5 days
Legs and abdomen ………. 7 – 10 days
Back and soles …………… 10 – 14 days
Face: 3-4 days Scalp: 5 days Trunk: 7 days Arm or leg: 7-10 days Foot 10-14 days
How? Many patients are very apprehensive about suture removal, so the first step is to reassure the patient that the procedure is not painful. The skin should be cleansed. Hydrogen peroxide is a good choice for gently removing dried blood and exudates.