The document discusses high-vacuum wound drainage systems for post-operative drainage from pfm medical ag. It offers a variety of drainage systems for all clinical applications using high-vacuum drainage. The systems provide concise summaries in 3 sentences or less that provide the high level and essential information from the document. It discusses the goals and advantages of using high-vacuum wound drainage systems, including preventing fluid accumulation, relieving surrounding tissue, improving wound contact, faster patient mobilization, and removing abscesses. It also provides a general product description of high-vacuum drainage system components.
Novel technique of mastectomy for breast cancer presenting as an abscess KETAN VAGHOLKAR
Association of an abscess with breast cancer is quite uncommon. Breast abscess encountered in a non-lactating woman should be considered as a malignancy until proven otherwise. A case of malignancy of the breast presenting as an abscess is presented along with a novel technique of mastectomy in such uncommon cases.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Gossypiboma, textiloma or more broadly Retained Foreign Object (RFO) is the technical term for a surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body
Dr.Pragnesh Shah is Gynaecological Endoscopic surgeon from Ahmedabad,Gujarat,India and having keen interest in Gynaecological Endoscopic Training. He is having experience of most of the difficult and complicated laparoscopic and hysteroscopic surgeries with world class infra structure in Ahmedabad.
He has given Gynaecological Endoscopic Training to many Gynaecologists and surgeons of the world.
Most ovarian abnormalities can be managed laparoscopically. Ovarian pathology can occur at any time from fetal life to menopause. First laparoscopic salpingooophorectomy was performed by Semm in 1984.
Novel technique of mastectomy for breast cancer presenting as an abscess KETAN VAGHOLKAR
Association of an abscess with breast cancer is quite uncommon. Breast abscess encountered in a non-lactating woman should be considered as a malignancy until proven otherwise. A case of malignancy of the breast presenting as an abscess is presented along with a novel technique of mastectomy in such uncommon cases.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Gossypiboma, textiloma or more broadly Retained Foreign Object (RFO) is the technical term for a surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body
Dr.Pragnesh Shah is Gynaecological Endoscopic surgeon from Ahmedabad,Gujarat,India and having keen interest in Gynaecological Endoscopic Training. He is having experience of most of the difficult and complicated laparoscopic and hysteroscopic surgeries with world class infra structure in Ahmedabad.
He has given Gynaecological Endoscopic Training to many Gynaecologists and surgeons of the world.
Most ovarian abnormalities can be managed laparoscopically. Ovarian pathology can occur at any time from fetal life to menopause. First laparoscopic salpingooophorectomy was performed by Semm in 1984.
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Bone marrow aspiration & trephine biopsySanjeev Kumar
Bone marrow aspiration & trephine biopsy, Complication of BM Aspiration, Clinical significance, Indication of Bone Marrow Aspiration and Biopsy, Types Of Needles, Site for Bone Marrow Biopsy And Aspiration, types Of Smear for Bone Marrow, Advantages of Bone Marrow Trephine Biopsy
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak After Endovascular Abdominal Aortic
Aneurysm Repair
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Bone marrow aspiration & trephine biopsySanjeev Kumar
Bone marrow aspiration & trephine biopsy, Complication of BM Aspiration, Clinical significance, Indication of Bone Marrow Aspiration and Biopsy, Types Of Needles, Site for Bone Marrow Biopsy And Aspiration, types Of Smear for Bone Marrow, Advantages of Bone Marrow Trephine Biopsy
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak After Endovascular Abdominal Aortic
Aneurysm Repair
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Anastomotic dehiscence after colorectal surgeryKETAN VAGHOLKAR
Anastomotic dehiscence after colorectal surgery can have disastrous consequences. Various factors determine the
chances of anastomotic failure. The technical and systemic factors which a surgeon needs to be aware of are presented
in this article.
Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in a stand-alone Daycare Surgery Center in South India.
RCT on Base tie in laparoscopic appendecomy (Journal Club).pptxadnanhabib31
This is ppt made on a study based on Randomised controlled trial on the tie of appendix base in laparoscopic appendectomy by hem-o-lok,endoloop or stapler.This study showed that hem-o-lok clips are better and cheaper as compared to others.
Similar to Wound drainage-information-booklet-pue1201 (20)
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Colonic and anorectal physiology with surgical implications
Wound drainage-information-booklet-pue1201
1. The product portfolio for post-operative
wound drainage from pfm medical ag
offers a variety of systems for drainage
by high-vacuum for all clinical
applications.
www.pfmmedical.com
Quality and Experience
Post-operative
wound drainage
›
High-vacuum drainage
2. 2 08.02.2013_Rev02_DRAFT
Contents
Foreword 3
Drainage in breast surgery 4
Introduction and description of problem 4
Drainage systems (vacuum drainage) 6
Goals of using high vacuum wound drainage systems 6
General product description 7
Sequence of events in would healing / Application of vacuum drainages 8
Drain placement in a wound 9
Advantages and disadvantages of high vacuum drainage 10
Managing drainage systems in breast surgery:
A Manual 11
General principles of draining wound cavities in breast surgery 11
Placement drainage system 12
Case examples 13
3. 08.02.2013_Rev02_DRAFT 3
Foreword
Foreword
For over 200 years people have known how important it is to drain off body fluids. At first, metal tubes were used as
drains, but only after the secretions had already occured. Prophylactic wound drainage was first used by Heister in
1719. His technique made use of the principle of capillarity and is known today as a Penrose drain. In 1954, after cen-
turies of improvement to the familiar drainage principle and experiments with negative pressure drains, Redon and
colleagues succeeded in developing a high vacuum system for prophylactic drainage of wounds. This system enabled
patients for the first time to be mobilised quickly. Redon drainage underwent many improvements during the rest of
the past century, as did conventional gravity drainage. Low vacuum systems were also developed, making it possible
to apply the principle in other fields as well. Today, development of clinical routine in wound drainage has reached a
point where only detail improvements are possible. Further changes to the basic principle are unlikely.
Overview of the milestones in the history of drainage techniques
Antiquity
Removal of pathological accumulation of secretion with metal tubes,and later with tubes
made from stainless steel
1719 Heister (GB)
First prophylactic wound drainage (Penrose drain)
1851 Chassaignac Potain (F)
First prophylactic wound drainage by suction
1898 Buelau (D)
Siphon drainage in which suction is created with the aid of a waterjet pump
A modified form of Buelau drainage is still in use today for thoracic drainage
1898 Heaton (USA)
Thoracic drainage with a suction pump driven by an electric motor
1949 Raffl (USA)
Motor-driven low vacuum wound drainage
1954 Redon,Jost,Troques (F)
Redon suction drainage (evacuated glass bottles with Redon suction drains)
1971 Introduction of pre-evacuated disposable plastic bottles
pfm medical GmbH founded by Jürgen Wolter
2000 Versatile application of drainage for many indications
4. 4 08.02.2013_Rev02_DRAFT
Drainage in breast surgery
The formation of seromas is one of the most common complications following breast surgery. The sequence of events
causing them is unclear.However it is possible to define subgroups of patients of whom a high percentage develop sero-
mas leading to complications.Especially in these cases primary and secondary seroma formation can be reduced by using
seroma-minimisingtechniquesandinstrumentsinthefirstplace.
The basic principle in minimising the formation of seromas and haematomas is the diminution of wound cavities or
so-called obliteration of dead space. This means actively adhere the areas mobilised, where extensive spaces are to be
dissected,e.g.withactive drainage creating negative pressurein thewoundarea.Highvacuum drainage systems have this
effect.
In the literature the incidence of seromas is reported as being between 15 and 81%.This makes seroma formation the most
commoncomplicationofwounds.
A quality survey in the field of breast surgery performed in Bavaria, Germany, showed that, of 10,233 women undergo-
ing breast surgeries in certified breast centres,29.6% developed seromas.The different periods of time spent in hospital
dependpartlyoncomplicationssuchasbleeding/haematomaandseroma(seefollowingtable).
Basic statistics Hospital
Direct comparison
(38 breast centres,
German cancer association)
Total
(165 hospitals/departments)
Patients 2011 Prev.year 2011 Prev.year 2011 Prev.year
n % n % n % % n % %
Data sets
Patients 425 100.0 408 100.0 10,233 100.0 100.0 15,272 100.0 100.0
Unilateral treatment 404 91.6 377 92.4 9,993 97.7 98.3 15,037 97.7 98.1
Bilateral treatment 39 8.4 31 7.6 240 2.4 1.7 365 2.3 1.9
Operations 504 100.0 439 100.0 10,571 100.0 100.0 16,194 100.0 100.0
Operations per patient 1.1 1.1 1.0 1.0 1.0 1.0
Operations per breast 1.0 1.0 1.0 1.0 1.0 1.0
Operation
Median duration of preoperative stay (days) 1.0 1.0 1.0 1.0 1.0 1.0
Operation on day of admission 149 37.2 69 20.4 2,262 25.9 24.4 3,189 24.5 23.2
Operation on next day 242 60.4 250 73.0 5,597 64.1 65.5 8,555 65.6 66.7
Operation 2 – 4 days after admission 6 1.5 15 4.4 298 3.4 3.6 536 4.1 4.2
Operation 5 – 14 days after admission 4 1.0 4 1.2 292 3.3 3.7 451 3.5 3.9
Operation over 2 weeks after admission 0 0.0 1 0.3 275 3.2 2.5 294 2.3 1.9
Median duration of post-operative stay (days) 4.0 4.0 4.0 5.0 4.0 5.0
Outpatient surgery 0 0.0 1 0.3 20 0.3 0.4 49 0.4 0.5
Discharge on next day 7 1.8 5 1.8 469 5.4 5.0 710 5.5 4.8
Discharge after 2 days 45 11.2 11 12.1 1,020 11.7 10.3 1,506 12.2 10.7
Discharge after 3 – 7 days 301 75.1 249 73.2 5,780 56.3 54.9 5,425 64.6 82.9
Discharge after 8 – 14 days 46 11.5 40 11.8 1,166 13.4 16.4 1,883 14.5 18.0
Discharge after 15 days or more 2 0.5 3 0.9 209 3.0 2.9 378 2.9 3.1
Drainage in breast surgery
PaepkeS.,GrosseLackmannK.,EttlJ.,PaepkeD.,KiechleM.
Introduction and description of problem
5. 08.02.2013_Rev02_DRAFT 5
Drainage in breast surgery
Seromas can have different causes. Most commonly they result from proinflammatory and inflammatory exudative
processes in soft tissue.These are intensified by the release of lymph fluid occurring when lymph vessels are cut during
breastsurgeryorwhenlymphnodesareremovedinlymphadenectomiesinbreastsurgery.
The lack of a clear definition of the term “seroma”,which reaches beyond the description of fluid accumulation in the
wound cavity, is also a problem. The variation and lack of clarity in the definition make it difficult both to record the
clinical situation and to make reliable scientific statements. The relevance of seroma formation varies considerably,
especiallyasthedegreeofsymptomdevelopmentisnotnecessarilydependentonsize,uptoaclinicallynoticeablevolume.
Any surgical procedure has a risk of leading to seroma formation,whether performed with a scalpel,by electrosurgery or
using modern cutting techniques.Thermal and mechanical damages of tissue areas – adipose tissue,lymph vessels and
musclefasciainbreastsurgery–areestablishedfactorsinthisprocess.
Seromas are also formed as a result of acute inflammatory exudates in reaction to surgical injury,e.g.with large wound
areas and incompetent sealing after mastectomy,intensified by the removal of sufficient lymph vessels and lymph node
tissueasinflammatoryexudateswithoutbacterialcolonisation.Axillarydissection,resultinginbloatingofthetissuewith
axillarylymph exudate,is also a cofactor.The self-maintaining process of exudate formation is also problematic because it
causes the wound surfaces to move apart so that local tissue connecting factors cannot act.The result is dead space which
favoursincreasedseromaformation.
Seromas can cause various problems.The main complications are caused by infections and other disruptions of wound
healing. Their effect on further stages of treatment is also different, e.g. after breast surgery. Seromas per se present
problems when planning and carrying out radiotherapy but do not,themselves,present an obstacle to systemic therapy.
The resulting complications alone can cause delays in further stages of treatment. Such complications follow seroma
formationinabout15%ofcases.
Seroma formation has been found to be increased by the use of heterologous materials in reconstructive breast surgery,
e.g.implants,meshes and acellular dermal matrices.In these cases the duration of drainage is longer than average and an
abruptincreaseisseenintheoccurrenceofsecondaryseromas(seromasformingafterdrainagetubeshavebeenremoved).
Highly specialised hospitals, where operations with these materials are performed, thus record a higher incidence of
complications.
Active high vacuum suction is the key treatment approach for preventing the formation of clinically or radiologically
significantseromasandtheirafter-effects,whateverthepotentialcausemaybe.
Source:BAQdata,Bavaria/Women’shospital
Basic statistics Hospital
Direct comparison
(38 breast centres,
German cancer association)
Total
(165 hospitals/departments)
Complications 2011 Prev.year 2011 Prev.year 2011 Prev.year
n % n % n % % n % %
Post-operative treatment-related
surgical complications
56 14.0 42 12.4 552 5.3 6.7 749 5.8 6.1
Wound infection 8 14.3 10 23.8 99 17.9 17.7 121 16.2 18.1
Bleeding/haematoma 19 33.9 16 38.1 273 49.5 42.6 356 47.5 41.4
Seroma 20 35.7 13 31.0 158 29.6 35.1 234 31.2 35.3
Other 12 21.4 8 19.1 58 10.0 11.4 87 11.6 12.2
6. 6 08.02.2013_Rev02_DRAFT
Drainage in breast surgery
Goals of using high vacuum wound drainage systems
Preventing accumulation of secretion,blood and lymphatic fluid
Every operation involves some intra-operative bleeding.Similarly,post-operative bleeding are not always avoidable.This
bleeding occurs in a closed wound space and leads to haematomas or seromas that are cut off from the blood circulation
and hence from the body’s own defences.They create an ideal culture medium for microorganisms.
Relief of surrounding tissue
Intra- or post-operative haematomas or seromas compromise the adjacent tissue surrounding the wound space.
This interferes with natural wound healing and,in a few cases,can lead to infections.
Improving wound area contact
Haematomas and/or seromas hinder contact between the affected wound areas. This may lead to a prolonged healing
process.
Faster patient mobilisation
Faster wound healing leads to faster mobilisation of patients and thus to a shorter stay in hospital. This benefits the
patient and also saves costs.
Removal of abscesses (emergency indication)
Should pus accumulate in newly created tissue cavities that are closed on all sides,it can be released by means of targeted
drainage.
Vacuum drainages actively suck out wound secretions by exerting negative pressure.This means they are able to drain
off cells and fluids out of the wound cavity more effectively than passive systems.The edges of the wound continue to be
pulled towards each other and stabilised by the vacuum.The process is known as wound edge alignment.
Vacuum drainage systems can be divided into:
High vacuum drainage
These systems work with an average pressure difference
of about 900 - 990 mbar.
Drainage systems (vacuum drainage)
Low vacuum drainage
These systems work with an average pressure difference
of about 100 - 250 mbar.
Unlike lowvacuum drainage systems,highvacuum drainage systems use pre-evacuated bottle systems with rigid walls.With
exception of contraindications, such as the use in serous membranes, high vacuum drainage systems can be usefully
applied almost universally.They are ideal for cleansing large wound areas because of their strong suction capability and
the large capacity of the bottles.
7. 08.02.2013_Rev02_DRAFT 7
Drainage in breast surgery
General product description
①
Drain connector
②
Connection tube
③
Tube clamp
④
Bottle clamp
⑤
Tubing connector
⑥
Hanger / Vacuum-level indicator
⑦
Quick fastener
⑧
Vacuum indicator
⑨ Rough graduation
⑩
Fine graduation
Redon drain
Parts ①,② and ③ are only included in the
OR system packs.
Part is only included in special packs (Redon sets)
and is shown here for information purposes only.
Both the OR systems and ward systems are available
with Luer Lock connectors on the connection tube ②
and/or tubing connector ⑤.
18 16 14 12 10 08 06
10
10
1 11
CH
1
2
3
4
5
6
7
8
9
10
min
max
max.
min.
max.
min.
18 16 14 12 10 08 06
10
10
1 11
CH
1
2
3
4
5
6
7
8
9
10
min
max
max.
min.
max.
min.
Vacuum
preset
No
Vacuum
preset
Fig. 1
Fig. 2
8. 8 08.02.2013_Rev02_DRAFT
Drainage in breast surgery
The wound has been closed with sutures.A fluid consisting of blood,cells and bits of tissue has accumulated in the wound
cavity. The blood in the wound cavity starts to coagulate from the ground of the cavity upwards. A haematoma forms
and stops the bleeding.The haematoma presses on the surrounding tissue making this process painful for the patient.
Leucocytes enter the area through the tissue and surrounding vessels. Together with further substances reaching the
area via blood vessels, these leucocytes act to dissolve the haematoma in the wound cavity. This process is associated
with an increase in the acidity of the surrounding tissue, which swells as a result.At this stage the wound can easily
burst open,letting in bacteria present on the skin.These are only facultatively pathogenic but can cause infection of the
wound.After the blood clot has been dissolved,the actual healing process begins.The wound cavity needs to be bridged
with new (scar) tissue.
The duration of this phase depends on the size of the wound.With larger surgical wounds it can easily take 7 - 10 days.
Renewed bleeding can occur if the wound is moved during this period. Healing time may additionally be extended by
several days if the egdes of the wound are also moved against each other.With repeated movement healing can even take
weeks longer.
When using a vacuum drainage the process of wound healing is significantly reduced due to the following reasons:
•
Blood,cells and tissue residues are sucked out of the wound cavity.
•
The edges of the wound are drawn together and fixed by the negative pressure being exerted in the wound cavity.
This means:
•
No haematoma is formed.
•
As there is no haematoma to be broken down,the wound does not swell.
•
The space that needs to be filled with new tissue has become considerably smaller.The wound cavity can be bridged
with new tissue more quickly.
•
The edges of the wound can no longer shift against each other because they are fixed by the vacuum.
In large wound cavities or wounds with rigid boundaries (orthopaedics and trauma surgery) active drainage systems are
the only logical choice as a drainage process would not start without suction from outside.
Cross-section of wound PRIOR application of vacuum Cross-section of wound AFTER application of vacuum
Sequence of events in would healing / Application of vacuum drainages
9. 08.02.2013_Rev02_DRAFT 9
Drainage in breast surgery
Figure 2:
The Redon drain has three rings marking its distal end to
prevent it from being pulled too far through.
Figure 3:
After the trocar has been separated from the drain with
sterile scissors (not shown) the drain is fixed to the skin.
This prevents it from being pulled out unintentionally.
Figure 4:
The distal end of the drain is now at the lowest point in the
wound cavity.The drain is connected to the drainage tube
of a Redon surgery system using a universal connector.
Drain placement in a wound
In most cases after surgery a trocar or a guide needle with a drain attached is passed out of the wound cavity through
the skin.The exit point of this drain is below the actual wound so that the incision is not exposed to an increased risk of
infection.This also prevents the wound from being reopened after it has been closed with sutures as a result of pulling
on the drainage tube.In most cases the trocar leaves the body at a distance of about 5-10 cm from the wound.The distal
end of the drain should be at the lowest point in the wound or as far away as possible from its exit point.This makes it
impossible for blood to accumulate under the area to be drained.The drain perforations may not extend above the edges
of the wound.The proximal end of the drain is,accordingly to kind and extent of the drainage,embedded in the bandage
or connected to a container.
Figure 1:
Using a trocar to lead the drain out of the wound cavity.
The distance from the wound in this case is about 5 cm.
10. 10 08.02.2013_Rev02_DRAFT
Advantages Disadvantages
•
Due to the strong suction of these systems efficient
cleansing of the wound area is effected. Serum, cells,
germs, mediators and tissue remain efficiently from
the wound area.
•
A closed system reduces the risk of infections. A
system is 100% closed except at changes of collecting
vessels. If the right bottle size is selected it may not be
necessary to change bottles. It is not necessary to re-
evacuate the collecting vessel. This also protects the
surroundings against potentially pathogens.
•
Patients may be troubled by the relatively large, heavy
collecting vessels for high vacuum drainage systems
(usually Redon bottles).
•
Although it is generally possible to examine the
wound and test the fluid secreted, it is difficult to take
samples hygienically from a Redon bottle. This is a
result of the principle being applied. The Redon bottle
is part of a closed wound drainage system and is not
allowed to release any secreted fluid.
•
Strong suction inhibits retrograde infection. If
bottles are exchanged correctly a constant vacuum is
maintained within the system (in the tube, drain and
wound) which prevents germs from climbing back
towards the wound.
•
High vacuum systems should not be placed in contact
with vasculature, nerves or organs that could be
damaged by the vacuum system. Direct contact bet-
ween the drain and the bowel should be avoided. High
vacuum drainage systems are also contraindicated in
serous membranes. Attention should also be given to
any other contraindications that are known of within
the individual departments.
•
The systems offer easy handling. If more fluid is
collected than was expected, vessels are changed very
quickly. Re-evacuation is not necessary. This means the
ward staff needs to spend less time and effort on it.
•
The volume of the vessel is used effectively because of
the high negative pressure. Viewed in physical terms,
100 per cent of the vessel would be used in the case
of a 100 per cent vacuum (0 mbar). With a 90 per cent
vacuum (100 mbar) still 90 per cent of the vessel volu-
me would be used. With a 400 ml Redon bottle this is
equivalent to 360 ml.
•
As shown on page 8, the edges of the wound are pulled
together and fixed by the high negative pressure. This
results in a much shorter wound healing phase and
therefore a shorter hospital stay for the patient.
Advantages and disadvantages of high vacuum drainage
Drainage in breast surgery
11. 08.02.2013_Rev02_DRAFT 11
Managing drainage systems in breast surgery
Managing drainage systems in breast surgery: A Manual
PaepkeS.,GrosseLackmannK.,EttlJ.,PaepkeD.,KiechleM.
Choiceofdrainagesystem
Thechoiceofdrainagesystemwithregardtotubediameterdependsontheexpectedaveragevolumeoffluid.Additionally,
itdependsonwhetherthechoiceofdrainagesystemalsodependsonwhetherbothhaematomasandseromasneedto
bedrained,inwhichcasedrainagesystemswithalargerlumenarepreferable.Ifbloodislikelytobereleased,clotting
processescanleadtocoatingoftheinnerwallsofthedrainagetubeandcanevenpartiallyblockthelumenbyproducing
smallerorlongerbloodclots.
Thechoiceofsizeofthedrainagesystemalsodependsontheexpecteddurationofdraining.
Ithasoccasionallybeenpostulatedthatdrainagesystemsperseincreasetheriskofwoundinfection.Thisisnotconfir-
med,eitherinourexperienceorbydataintheliterature.
Placingdrainagetubesinthewoundarea
The aim in positioning the drainage tubes is to achieve the greatest possible contact area in relation to the wound area.
Theopenlumenofthedrainagetubeshouldlieintheregionwhereseromaformationisexpectedtobegreatest.
General principles of draining wound cavities in breast surgery
12. 12 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
Trocarpushingthrough
Suture:Fixationtotheskin
Disinfectionouterwoundsurface
Suture:Bridgeformationforbettertubemobility
Exampleofcomplications:
Seromaafterremovalofdrainagetube
Exampleofcomplications:
Subcutaneoushaematomawithinsufficientdrainage
Placement drainage system
13. 08.02.2013_Rev02_DRAFT 13
Managing drainage systems in breast surgery
Casedescription1
Highvacuumsystemfordrainageoflargewoundareaswithanexpectedseromafluidquantityof50ml/dayinlarge-scale
breastsurgery
Case:
Secondarywoundhealingproblemsafterradicalmastectomyandaxillarylymphnodedissection
78-year-oldpatient
First operation 24 days earlier, secondary wound healing problems with wound dehiscence and granulation starting to
occurfromthewoundbed.Microbiologicalsmears:bacteria-free.
Problems:
As well as the clearly visible wound dehiscence,the large wound cavity also presents a problem.A seroma,which formed
primarily after surgery,prevented the wound surfaces from healing onto the thoracic wall.A large dead space was created
inthewholeablationareaasaresult.
Strategy:
Excision of wound edges along the full length of the scar and freshening up to vital tissue in the skin and on the thoracic
wall.Absolutelythoroughdisinfectionanddraining.
Expecteddrainagevolume75mlforthefirstfewdayswithconsecutivereductionashealingproceeds.
Note:
Allstagesaretobecarriedoutbytrainedmedicalstaffapplyingsurgicalstandards(hygieneetc.).
Situationatstart:
Sterilisation,drapinginoperatingroom.
Choiceofdrain:
pfmmedicalhighvacuumRedondrainagesystem,
diameter18Fr;bottlevolume600ml,highvacuum
980mbar;luerlockconnectorforbottlechangesthatwill
benecessarylater.
Case examples
14. 14 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
Surgicalsituationafterexcisionofwoundedgesandsurgi-
calfresheningofallwoundedges.
Thelengthofthewoundis14.5cm.
Paralleltothoroughdisinfectionofthewoundcavitythe
theatrenursepreparesthedrainagesystem.
Thenon-sterilenurseopenstheouterpackagingofthe
drainagesystemandpassesontheinnersterilepackage.
Thesteriletheatrenursetakesthesterilepackagefromthe
drainageset.
Thesteriletheatrenurseplacesthedrainagesystem
componentsseparatelyontheinstrumenttable.
ThesecomponentsareaRedontubesystemwith
connectedtrocarandahighvacuumbottlesystemwith
tubeconnector.
15. 08.02.2013_Rev02_DRAFT 15
Managing drainage systems in breast surgery
Thesiteoftheskinpuncturemadewiththetrocar,to
whichtheRedondrainisconnected,ischosenunderconsi-
derationofthefollowingpoints:
• distantfromthewound(about5cm);
•
atthelowestanatomicalpointtomakeuseoftheforceof
gravityaswellasthehighvacuumofthesystem;
•
followingthefunctionalaspect,sothatthelateralpla-
cingofthedrainagetubelimitsthepatient’smobilityas
littleaspossible.
•
thepunctureareaisdisinfectedagainbothinsideandout.
Thehandontheinsidemarksthepointoftheinnerdrainage
punctureandliftsthewoundsurfacetoseewhetherthere
arebloodvesselsintheskinsothattheyarenotinjured.
Thehandguidingthetrocarplacesthetrocarparalleltothe
thoracicwalltominimisetheriskofinjury.
Thetrocarisinsertedwhileliftingawideareaofthewound
surfacetoensurevisibility.
Itispushedslowlybutforcefullythroughtheskin.
16. 16 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
Afterthewholetrocarhasbeenpushedthrough,thenon-
perforatedpartoftheRedondrainispulledoutabout10cm.
TheRedondrainiscutdiagonallyjustabovetheconnec-
tionbetweentheRedondrainandthetrocar.
TheperforatedsectionoftheRedondrainisplacedinthe
caudalandmedialpartofthelargewound.
Thisensuresthatthelowestanatomicalpointofthewound
areaismaximallydrained.
AttachmentoftheRedondrainbysuturesothattheknot
enclosesthedrainsoftlybutfixesitfirmly. Thissecures
theRedondraininpositionandpreventsconstrictionof
thediameter.
17. 08.02.2013_Rev02_DRAFT 17
Managing drainage systems in breast surgery
Aplug-inconnectionjoinsthedistalendoftheRedon
draintotheproximalendoftheconnectiontubetothe
highvacuumbottle.
JoiningthedistalendoftheRedondraintothe
highvacuumbottle(luerlockconnection).
Themulti-levelconnectoriscutoffattheproximalendof
theconnectingtubesystemtojointheRedondraintothe
highvacuumbottle(at18Frasappropriateforthediameter
chosenforthewholesystem).
Finalpictureofthesurgicalsiteafterlayeredwound
closurewithsterileself-adhesivestripsalongandacross
thewoundtoreleasetensionatthewoundedges.
Thedrainagesystemisfixedwiththedistalendofthe
Redondrainstillopen.
18. 18 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
Afteranoverallclosed,completelysterilesystemhasbeen
createdthehighvacuumisactivatedbymanualopeningof
thesealingsystemattheproximalendofthehighvacuum
suctionbottle.
TheRedonsystemisdisinfectedagainandasplitdressing
isappliedtotheskintokeeptheareasterile.
Finalstateofhighvacuumdrainagesystemsite:dressed
wound,dressedsiteatwhichdrainagetubeleavesthebody,
totallyclosedsystemwithactivehighvacuum.
19. 08.02.2013_Rev02_DRAFT 19
Managing drainage systems in breast surgery
Casedescription2
High-vacuumdrainagesystemforsmallwoundcavitiesinsmallbreastoperations
Casepresentation:
56-year-oldfemalepatientwithPaget’sdiseaseofthenippleanddirectretroareolarDCIS,confirmedbyhistologicalexami-
nation(surroundingareaof5x9mmsuspectedofcontainingmicrocalcifications).
Indications to remove the nipple and a retroareolar segment of tissue with the aim of rebuilding the nipple from the
remainingareolarskinusingtheskateflaptechnique.
Expecteddrainagevolume15ml/dayfor2days.
Note:
Allstagesaretobecarriedoutbytrainedmedicalstaffapplyingsurgicalstandards(hygieneetc.).
Postmenopausalfemalepatientwithhistologicallyconfir-
medleftcentralDCISassociatedwithmicrocalcifications.
Itisplannedtomarktheextentofmicrocalcification
mammographicallywithawireandthentoremovethe
segmentviaaperiareolarincision.
Itisestimatedthatthequantityoffluidtobedrainedasa
resultofthevolumedeficitcausedbysegmentremovalwill
beabout35-50mlperdayfor1-2days.Ithasbeendecided
touseahighvacuumsuctiondrainagesystem(980mbar)
andatrocarwithasharptip,12Fr(4mm)drainagesystem,
totaldrainagevolume200ml.
Thenon-steriletheatrenurseopensthenon-sterilecovering
andpassesthesterileinnerbagwiththedrainageandtrocar
systemtothesteriletheatrenurse.
20. 20 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
Thesteriletheatrenursetakesthedrainageandtrocar
systemoutofthesterileinnerbag.
Thesteriletheatrenursetakesoutthesterileinnerbag
containingthedrainagebottle.
Thesteriletheatrenursetakesthedrainagebottleoutofthe
sterileinnerbag.
Thesteriletheatrenurseshortenstheplug-insystemofthe
drainagetubetofittheplug-insystemofthedrainagebottle
tobeconnected.
21. 08.02.2013_Rev02_DRAFT 21
Managing drainage systems in breast surgery
Viewintothesegmentectomycavitywhichisheldopen
with4Rouxretractorsandfreeofblood.Thedrainage
systemcannowbepositioned.
TheRedondrainisplacedinthesegmentectomycavity.
Thetrocarisinsertedthroughtheskinatthelowestpoint
inthesegmentectomycavity.
Thetrocarleavesthebodyatthelowestpointinthe
segmentectomycavityintheareaofthesubmammaryfold.
TheRedondrainiscutoffjustabovethetrocarneedle.
Thecutisdiagonaltogiveabetterconnection.
22. 22 08.02.2013_Rev02_DRAFT
Managing drainage systems in breast surgery
TheRedondrainisfixedwithaslowlyabsorbablesuture.
Theproximalendofthedrainisplacedinthesegmentec-
tomycavitysothattheopeningsintheRedondrainthe
woundaseffectivelyaspossible.
Caremustbetakentoensurethatallthedrainageopenings
remaininthewoundarea(seemarkingonRedondrain).
Drainagecannowbeactivated.
TheendoftheRedondrain,whichiscutdiagonally,is
connectedtothecorrespondingendofthevacuumbottle
(push-fitconnection).Thiscreatesaclosedsystem.
24. Do you have any questions?
Our Customer Solutions Team
will be glad to advise you.
service@pfmmedical.com
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Fax +49 (0)2236 9641-51
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