drains

1. “ Use of drains in
gastrointestinal Surgery
Dr sumer yadav
ms general surgery , mch plastic and
reconstructive surgery

2.  A channel by which surplus liquid is drained
or gradually carried out.
 An appliance or piece of material that acts as a
channel for the escape (exit) of gases, fluids and
other material from a cavity, wound, infected
area or focus of suppuration.
 Drains inserted after surgery help the wound
to heal faster and assist in preventing infection.

3.  Hippocrates –drainage of empyema, ascitic fluid
 200AD- Celsius devised means of draining ascites
with conical tubes
 1700AD –Johann Schltetus-1st
person to use
capillary drainage
 1897AD Charles Penrose devised Penrose drain
 1932AD Chaffin developed 1st
commercially
available suction drain
 1959AD silicone rubber discovered and advantages
were reported by Santos

4.  Soft -Minimal damage to surrounding tissues
 Smooth -Efficiently evacuate effluent and easy
removal
 Sterile- not potentiate infection or allow
introduction of infection from external
environment
 Stable- Inert, non allergenic, not degraded by
body
 Simple to manage by both patient and staff

5.  To remove unwanted fluid/ exudate
/pus/gas
 To allow monitoring of fluid volume & quality
 To promote tissue apposition
 To allow diversion of body fluids
 To facilitate subsequent access to a body
space or cavity
 To diagnose about underlying cavity or fistula

6.  Haematoma
 Other Fluids (serous,
chyle, pus, etc)
 Tissue adherence --
cosmesis

7.  Greater tissue contact
 Inert material.
 Slides smoothly past any tissue
 Promotes ease of movement and deep
breathing
 Minimal pain on removal
 Comes in various sizes

8.  Laminar flow through drain
 Poiseuille’s law
F =dP πr4
/8nL
 F = flow of fluid thru the drain lumen
 dP =pressure difference between the two ends
 n =viscosity
 L= length of drain
 Flow directly prop to suction pressure, radius
 Indirectly prop to viscosity and length of drain
 Double in drain diameter 16 fold increase in
flow
 Halving the length will double the flow

9.  According to Poiseuille’s law the laminar flow
rate of an incompressible fluid along a tube is
proportional to the fourth power of radius of
tube and suction pressure. Flow is inversely
proportional to viscosity of the fluid and length
of the tube.
 It means that wider and small length tube
have more flow rate.

10.  Factors governing effluent movement
 Gravity
 Capillary action
 Tissue pressure
 Negative pressure

11. a. Prophylactic :-postoperatively to prevent
accumulation of fluid or to detect early any
leakage from anastomosis site.
b. Therapeutic :-to evacuate an existing collection.
i.e. lymph, pus, urine saliva, serum
c. Diagnostic :-MCUG,T-tube cholangiogram

12. a. Open:-drains directly to the exterior .e.g.
Penrose and corrugated rubber drain. There
are less chances of blockage, more comfortable
to patient but more chances of infection.
b.Closed:-drains externally into a sealed container
so having less chances of infection, better skin
care, better care and accurate assessment of
fluid drainage.

13.  Internal drains
 Divert retain fluids form a body cavity to another
 Useful in neurosurgery, ctvs ,G.I surgery and
urology
 E.g. Celestine, southar tubes, V-P shunt, Pericardio-
pleural tube
 External drains
 Channel discharge from cavity to external
environment

14. 3.a.With suction :-where negative pressure is
applied to facilitate drainage. It allow the
drainage of fluid from areas where movement of
fluid is against the natural pressure gradient,
also helps apposition of tissue planes prevents
fluid accumulation and blockage of tube less
likely.
Disadvantage:-it also causes more tissue erosion
and prevent healing of an established fistula by
continued fluid drainage.
3.b.Non – Suction (passive ) drains

15.  a. Sump suction :-in this double lumen tubes
are there. Second tube act as a vent to allow air
flow down to the tip of a drain. This prevent
negative pressure at the tip and causes less
tissue erosion and less blockage.
 b. closed suction

16.  Irritant drains
 composed of materials irritant to tissues
 excite fibrous tissue response leading to fibrosis and
tract formation
 E.g. latex, plastic and rubber drains
 Inert drains
 Non irritant drains
 Provoke minimal tissue fibrosis
 E.g. polyvinyl chloride(PVC),polyurethane(PU)
silicon elastomer (silastic)

17.  Prior used red rubber or latex.(more chances
fibrosis and allergic reactions)
 Nowadays used polyurethane,
silicone(silastic), silicone elastomer, siliconised
latex or polytetrafluoroethylene(PTFE)

18. Material Example Properties
Latex rubber Penrose drain Soft, induces tract
formation
Red rubber Red rubber tube
catheter
Firm, induces tract
formation
PVC Chest tube Firm ,induce some
inflammation
Silastic Jackson-Pratt drain Soft, induces minimal
inflammation
Heparin coated silastic Jackson Pratt drain Aims to inhibit clot
formation and achieve
greater patency
Hydrogel coating Some foley
catheter,image guided
percutaneous drain
Produce slippery surface
resistant to encrustation
Polytetrafluoro-
ethylene(PTFE)
Some foleys catheter Latex + teflon.
Smoother than latex
Silicone elastomer Some foleys catheter latex +silicone –more
resistant to encrustation
Polymer hydromer Some foleys catheter Latex bounded with
.smoother than latex

19.  Should not exit cavity through same surgical
incision.
 Reach skin by safest shortest route
 Appropriate size and length
 A gravity drain must be placed in the safest and
most dependent recess in cavity
 Must be inserted away from delicate structures
 Firmly secured at exit wound
 Appropriate care-dressing,emptying.
 Must be removed when no longer useful-at once or
by progressive shortening

20.  What is being drained
 Consistency,-larger lumen, suction drain
 Why is the drain needed
 Latex, red rubber for tract formation
 Where is the drain located
 Related to delicate structures,
 Sterile sites-closed drain
 Negative pressure zones-underwater seal

21.  Trauma to tissues during insertion and
removal
 Fistula formation/perforation –erosion of
adjacent tissues
 Visceral herniation through tract
 Anastomotic leak
 Flap necrosis
 Bacterial colonization and sepsis

22.  Fluid and electrolyte loss
 Pain
 Restricted mobility
 Drain malfunction-migration,blockage,vacuum
failure
 Prolonged healing-delayed foreign body

23.  A substitute for poor surgical technique or
inadequate hemostasis
 Wrong indication
 Delayed removal
 Untimely removal
 Wrong selection of appropriate drain
 Inadequate care of drain
 Insertion in main surgical wound

25.  Abscess cavity
 Infected wound
 Must not adhere to
healing tissue
 Must contain an anti
septic
 must be replaced
frequently.

26.  Fistulae.
 Discharging sinuses.
 Same principles of
packs.

27.  Sheet drain wrapped
around a wick or pack
 Keep tract opened and
drain the inflammatory
exudates.
 Require less replacement

28.  Sheet drainage
 Simple insertion,
care and removal .
 Not expensive.
 Tissue irritant.

29.  Parallel tubes .
 Side and end holes.
 Thick fluid can block
drainage.

31.  When air tight seal
could not be
obtained.
 Suction machines
can be connected
intermittently.

32. Yeates drain
Rubber corrugated drain
Penrose drain

33. Hemovac drain
Jackson–Pratt drain
Foleys catheter Pigtail catheter

34.  Most effective
method of drainage.
 Require air tight
seal.
 Closed drainage.
 Allow better tissue
coaptation.

36. Intercostal catheter
Mediastinal catheter

37. Vacuum assisted closure (VAC) drain

38. 3-way Coude catheter
Foleys
catheter

39. Ryle tube
Fine bore NG tube

40. T-tube(Khers)
Salem sump tube

41. Celestine tube

42.  To allow decompression of gastric contents
 To reduce postoperative nausea and vomiting
 To reduce abdominal distension
 To lower risk of aspiration and subsequent
pneumonia formation.
 Study by Cheatam et al1995 shows slight postoperative
reduction of nausea & vomiting and more patient
discomfort.
 Study by Nelson et al2005 shows with non insertion of
tube showed less respiratory complications and
early return of gastrointestinal functions by early
passage of flatus.

43.  Acute gastric dilatation
 Duodenal fistula
 Gastric outlet obstruction
 Small bowel obstruction
 Nasogastric feeding

44.  Once anastomotic leak occurred drainage is
accepted as the treatment of choice
 In Cochrane review Karliczek et al2006 showed
drainage after routine colorectal surgery rate
of mortality, wound dehiscence, wound
infection, reintervention and extra abdominal
complications is quite similar in both drain or
without drain (573/1140).

45.  Petrowsky et al2004 showed both wound infection
rate subsequent fistula formation is lower if no
drain left irrespective of severity of
appendicitis.

46.  Lewis et al1990 showed no postoperative
reduction in complication.
 Cochrane review showed that postoperative
drainage increase wound infection rates
following open cholecystectomy also increases
incidence of respiratory complications.
 Same review showed increased rates of wound
infection and delayed postoperative discharge
in patients in which drain was used.

47.  Prophylactic drainage is generally
recommended for subphrenic collections and
biliomas after liver resection.
 But Cochrane review showed more chances of
infection of collection if drain is present and
recommends percutaneous drain placement
postoperatively.

48.  Used for decompression of oedematous CBD.
 To prevent biliary leakage.
 To provide access for postoperative
visualization and retrieval of retained stones.
 Trial by De-Roover et al, Sheen-Chen et al and
williams et al showed longer postoperative stay
in T- tube placement.

49.  Study done in perforated duodenal ulcer cases
(75/119) showed more chances of complication
as intestinal obstruction with drain placement.
 Study done in subtotal and total gastrectomy
cases (108) showed no difference in
complication rate.

50.  In pancreaticoduodenectomy for a lesion of
head of pancreas one drain is put near to the
pancreaticojejunostomy site and another near
the hepaticojejunostomy site.
 Study by Conlon et al in patient after
pancreatic resection rate of complication and
number of intervention for collection were
greater with drain.

51.  Used for reducing blood and fluid
accumulation.
 Study fails to clarify situation.
 Currently the placement of drain following
incisional hernia repair has to be at the
discretion of the operating surgeon.

66. Thanking youThanking you