DRAINS IN SURGERY

Chair person : Dr. Kempraj

Moderators : Dr. Mallikarjuna
Dr.Abdul Razack
Dr.Shanti Swaroop
Presentor: Dr. Suraj K Pattar ( PG ,general
surgery)
Outline
• Definition
• Purposes
• Principle
• Advantages & Disadvantages
• Sites of drain placement
• Types of drain
• Removal of drain
• Specific drains.
 HISTORY OF DRAINS

• Surgical drains have roots that extend back to

antiquities with the first written descriptions by
Hippocrates, who described using linens and
small tubes to drain infection from empyemas.
• Horsehair, linens, and silk
were often placed within the
drainage tube to assist with
capillary drainage.
• In the 1940s to 1950s,
closed system drains (sealed
from the atmosphere) and
sump drains (open to the
atmosphere) were
introduced.
 Definition : Drain is an appliance or piece
of material that acts as a channel for escape
of fluids –liquid or gas.
PORPOSES
1. Prophyactic-
a)to prevent accumulation of fluid (bile , lymph, exudate)
or blood.
b) to encourage the obliteration of dead space ,
2. Theurapeutic –
to promote escape of fluids already accumulated
3. others :
Divert fluid away from a blockage or potential blockage
Allow irrigation of a cavity
• Principle : The simplest and most effective method of
drainage is to bring the cavity to be drained to the
surface . As this is not always possible , alternatively an
artificial drain is passed down to the cavity to be drained.

Advantages
1. Reduce the risk of infection.
2. Prevent the accumulation of fluids such as blood, pus, bile or
lymph.
3. Allow early detection of anastomotic leaks.
4. Create tracts through which potential collections can drain.
5. Allows the raw surfaces to collapse and come in contact
with each other and enhance rapid healing.
• Disadvantages :
1. It forms the portal for entry for the bacteria.
2. It delays the healing .
3. It can breakdown the suture lines.
4. It frequently gets blocked.
5. It might initiate the tissue reaction.
 Classification of drains
Basis and factor types
Mechanism Active passive
Nature Tube Sheet/flat
Disposition Open closed
Location Internal external
property Inert Irritant
 Types of drains
1. Open drains .
2. Closed drains .

3. OPEN drain :
Drain into a dressing or a bag open to the air,
potentially increasing the risk of infection
Disadvantages:
• Collected fluid remains in contact with skin causing
maceration.
• The drained fluid may smell, there is a potential risk
of increased infection and open drains can be
painful to dress and change.
2. CLOSED DRAIN - drain into container systems.
they can be ,
a) active : connected to a suction source creating a
continuous pressure difference between the proximal
and distal end of the drain and drawing fluid from
inside to out.
b) passive: dependent on gravity and the pressure
differential between the body cavity and the exterior
in order for fluids to be drained.
OPEN DRAINS
1. COTTON guaze: these
are sheets of sterile
cotton . Placed on raw
surfaces , these act by
capillary action for
absorption of fluids .
Acts as temporary
drainage.
Disadvantages
a. Once it becomes saturated acts as a plug
rather than as a drain . So it should be
changed twice or every 24hr.
b. Acts as a moist channel for penetration of
bacteria.
c. It might damage the raw surfaces since it is
adherent to it .
2. Wicks .
• Wicks are formed from
guage or threads of
ligatures or suture
material twisted
together or bound
loosely. There are used
when the source of
infection cannot be
brought to the surfaces.
• Disadvantages : as it is made of guage it swells
upon soaking which will obstruct the tract.
• It can adhere to the surface.
• Requires frequent change because it
becomes in effective due to the soaking.
3.Red rubber corrugated drain(sheet drain)
• Made of red rubber .
• Available in the form of unsterile
sheets , from which the required
length and breadth are cut and
sterilized by autoclaving .

• With this the fluids reaches the

surface by gravity or vis-a-tergo ;
so it must be covered with a guage
piece.
• Advantages : drainage occurs along then grooves of
the drain , so less chances of blockage . Used only
when there is minimal discharge.

• Disadvantages:

– may lead to sinus formation.

– when used in peritoneal cavity , can injure intestine . It may
also breakup the suture lines, it might get sucked into the
wound when not fixed properly.
* currently portex drain is used as red rubber drain are
more irritant.
 USES of corrugated rubber drain
• Drainage of the peritoneal cavity after an operation

• Drainage of abdominal wall wound and perirenal area if

hematoma or infection is anticipated.

• To drain large abscess cavity like breast abscess or to drain

retropubic space

• To drain subcutaneous tissue after removal of multiple enlarged

lymph nodes in neck or groin.
4. Yeates drain
• It is a sheet formed of series
of parallel pvc tubes of
about 2mm in diameter
attached side by side.
• Disadvantages: very little
fluid passes through the
tubes which may easily get
blocked then fluid track
along the side of the tube
5. Penrose drain.
• It is a hollow tube of
latex rubber with a
thin wall, can be
made by cutting the
finger stall of surgical
glove.
• Not as rigid as yeates
or corrugated rubber
drain.
 CLOSED DRAINS
• TUBE drains : they have advantage that they can
lead away any content into the receptacle
• Fluid will flow only provided it is not viscous and
only if the tube is sufficiently wide so that air can
displace the fluid. However fluid empties by vis-
a-tergo.
• Usually the most effective method is to apply
suction. Insert the tube so the tip lies at the
lowest part where fluid is most likely to collect.
1. Portex drainage tubes : it is made of soft
portex. It is elastic and has side holes and
terminal hole . It causes least irritation. Can be
used for prolonged duration.
Uses: to drain pleural cavity in emphyema ,
hydropnemothorax , pneumothorax ,hemothorax.
to drain after an operation on heart or lung.
2. shirley drain : The Shirley wound drain
incorporates a side tube guarded by a bacterial
filter .

Clear aspirating tube allows positive visual

evidence that the vacuum source and drain are
working: “If it’s bubbling, it’s working.”
3. Malecots catheter
4. Sump drain :The
large outer tube creates
a sump in which fluid
collects. Lying freely in
the bottom of the sump
is a smaller tube
attached to a sucker.
Because the tissues are
separated from the
holes in the suction
tube, they cannot be
drawn in to block them.
 SITES
• Subcutaneous : Subcutaneous tissues vary in depth and
vascularity. Blood and reaction fluid collect

• Subfascial and intramuscular

• Extraperitoneal
• Intraperitoneal : soft tube drains are used in
intraperitoneal space.

• Pleural cavity : Although liquid such as an

effusion, pus or blood may be drained, an
important function of chest drains is to remove
air that has accumulated, has leaked after lung
damage or enters through a breach in the
thoracic wall.
Drain placement
1. The drain used should be: (a) soft, so as not to erode the
surrounding tissues
(b) smooth, so as not to permit fibrin to cling to it,
(c) preferably radio-opaque or having radio-opaque line along
the tube, (d) of a material that will not disintegrate and leave
foreign bodies and (f) it should be nonirritant.
2. Proper daily dressing of the drainage site should be done to
prevent infection.
3. It should not damage the nerve or blood vessel.
4. The inner end should not be placed near the suture lines.
 Precautions
• Drains act as a two way conduits .

• Drains should never be brought out through the

operative incision .
• Fix the drain properly with the skin stiches.
• Drain in the peritoneal cavity may promote
paralytic ileus and stimulate adhesions which
secondarily result in mechanical bowel obstruction.
• Too hard or stiff drains may cause pressure necrosis
of the surrounding tissue.
 Daily drain drill

The following questions should be answered on a daily

basis by the
surgical team reviewing the patient:
1 Volume of fluid (24-hour total)
2 Type of fluid?
3 Blocked, kinked, leaking or displaced?
4 Adequately secured?
5 Adequate suction
6 Ready for removal?
*Never rely on absence of blood in a drain to reassure you that the
patient is not bleeding.
Removal of drain.
• Drains placed in the perioperative period to
monitor bleeding removed after 24-48 hours
• Drains to remove serous collections – removed after
5 days
• Drains to remove infected materials – to be left until
the drainage becomes minimal and patient’s clinical
condition has improved
• T-tubes – to be left for 3-6 weeks to allow tract
formation
• Prior to removal of the suction drain, suction should
be switched off and drain monitored for 24 hours
Troubleshooting drains.
Issue Action
Thick inspisated pus/poor Twice daily drain flush with normal saline
drainage

Collection tubing kinked Reposition/consider using a drain bag

hanger

Collection bag empty Check: Is bag not opened (therefore

not working)
No fluid to collect

Suction grenade drain full Empty as this precludes any further

drainage
Intercostal drains
• Chest drains are a vital part of the management of
chest trauma and elective cardiothoracic surgical
procedures
• Indications for placement
• Air:
‘Simple’ pneumothorax;
Traumatic pneumothorax;
Tension pneumothorax after initial needlethoracocentesis;
• Fluid:
Haemothorax; Pleural effusion;
Infected fluid (parapneumonic effusion or empyema);
Chylothorax.
• Others:
Rib fractures and positive-pressure ventilation;
Fractures often associated with underlying lung injury at risk of
developing pneumothoraces
Relative contraindications
• Bleeding diathesis;
• Anticoagulation therapy.
Aims of chest drainage
• Drain air and/or fluid from the pleural cavity;
• Re-expand the lung and obliterate residual
spaces;
• Restore negative intrathoracic pressure.
Selection of chest drainage device
• Intercostal drain:
Infants and young children ---------8–12 French
Children and young adults --------- 16–20 French
Adults Air -----------24–28 French
Fluid/blood ----------- 28–40French
(28-36 m/c used)
How to insert a chest drain
• Where possible obtain verbal consent and pre-
medicate with an opiate, benzodiazepine or
ketamine.
• Check local policy for prophylactic antibiotics –
consider in trauma case.
• Locate triangle of safety .
Landmarks:
Anterior border of latissimus dorsi;
Lateral border of pectoralis major;
Horizontal line superior to level of nipple/fifth rib.
• Position patient to maximize access for yourself
• Using aseptic technique, prep and drape the axilla
and anterolateral chest wall widely.
• Aim for a site between the anterior and mid-axillary
lines above the nipple/fifth intercostal space to
avoid long thoracic nerve and breaching the
abdomen, respectively.
• Local anaesthesia (max. 3 mg/kg plain lidocaine).
Raise skin bleb then infiltrate deeper layers,
including the periosteum on top of rib before
progressing through pleura into pleural cavity.
Three-bottle set-up.
Drain removal
• Remove drain when:
The lung is fully inflated;
Bubbling or draining has stopped (100 mL/24 hours), with
minimal respiratory swing.
• Remove at end-inspiration or during Valsalva
manoeuvre, tie the pre-placed suture and apply an
occlusive dressing.
• Repeat a chest X-ray to document the lung position.
• Ensure the patient’s pain is well. Post removal chest
X-ray , physiotherapy , nebulisation, continue the
treatment for underlying disease.
Complications of ICD

• Pain: This is the most common complication.

• Damage to underlying thoracic or abdominal
structures: lung , viscera , diaphragm.
• Displacement: Usually occurs when the tube
is not pushed in far enough initially.
• Misplacement: Extrathoracic placement can
occur in obese patients.
• Infection .
Abdominal drainage kit

• Soft and smooth catheter with

collection bag of 2000ml and
large atruamatic eyes for
efficient drainage
• Radio-opaque line provided on
the catheter for x-ray
visualization
• Smooth and round distal end
• Catheter is marked at every
2cm from the last eye to
ascertain the depth of
placement
Hemovac drains(Closed wound suction unit )
It is suitable for close wound drainage under negative
pressure postoperatively with the option to operate one or
two catheters simultaneously.
It has a graduated bellow chamber. The sizes of bellow
chamber are 600 and 800 ml.
Equipment:
1. Bellow unit with connector
2. Connecting tube with clamp and 'Y' connecter
3. Curved trocar with catheter
4. Spare perforated redon drain catheter
5. The sizes for accessories are 6, 8, 10, 12, 14, 16, and 18 FG.
 • These are T – shaped
T - tubes with body and two
flanges.
• Whereas normal drains
are made of inert
silastic material which
does not excite a tissue
reaction, T-tubes are
made from rubber
drains and have the
opposite effect
INDICATIONS
Following bile duct exploration –
enables postoperative
cholangiography
and percutaneous extraction of
retained stones.
• Protect bile duct repair or
anastamosis – enables external bile
drainage while the
repair/anastamosis heals, thus
reducing the
occurrence of bile leak and biliary
peritonitis.
• T-tube cholangiogram can be performed at 2–3
days postoperatively. If this is normal, the T-
tube can clamped and secured to the patient.
• Removal is delayed for 3–6 weeks to ensure
that an adequate tract has formed, as early
removal can be associated with a leak of bile
into the abdomen.
• Gentle traction should be all that is required for
removal of the T-tube.
 Recent advances in drain
• Drains with one way entry valves to secure
against reflux of contaminated fluid
• Rotating garment clips to bring about
convenience to care giver
• Anti-thrombogenic coating of drains (both
internally and externally)
• High- and low-pressure vacuum drains are
commonly used after surgical procedures
• High-pressure vacuum drains (i.e, sealed,
closed-circuit systems) are efficient and allow
for easy monitoring and safe disposal of the
drainage.
• Low-pressure vacuum drains use gentle
pressure to evacuate excess fluid and air, and
are easy for patients to manage at home
because it is easy to reinstate the vacuum
pressure.
• Vacuum drains are classified according to the
degree of pressure used.
– Typical bottled vacuum drains (eg, Redi-vac) use
high negative pressure.
– Bulb-shaped suction devices (eg, Jackson-Pratt) and
collapsible four-channel vacuum drains (eg, J Vac,
Blake) use low negative pressure
Redivac drain
Jackson-Pratt drain
 BLAKE drain

Both are suction drains. JP has multiple side holes. Blake

has corrugated surface with side channels. The theory is
to evacuate fluids without the tube/drain getting
plugged.
 Complication and failures of drain.
• Inappropriate use of drains can lead to
complications that include infection and increased
overall patient morbidity.
• And also increase the risk for incision dehiscence or
delayed/failed wound healing.
•  a retrospective study showed that the risk for
major complications is low (4 [0.02%] of 228
patients
• Infection -Retrograde bacterial contamination,
including nosocomial infection
• Vascular Damage
• Spread of Neoplastic Cells
– In surgical oncology, use of drains is controversial.,
drains can disrupt tissue away from the primary
surgery site and seed these areas with neoplastic cells
• Dehiscence
– Drains should not be placed directly under an incision
line and should not exit through the suture line. Direct
contact with a healing incision can lead to a foreign
body reaction and increased risk for incisional
complications
• Blockage 
– Fenestrated drains placed in the abdominal cavity can
become occluded by omentum. To decrease the risk
for omental occlusion, the drain can be placed
between the liver and the diaphragm
• Electrolyte Imbalance
– A major complication of drain use can be changes in
electrolyte and/or serum protein levels
 Prophylactic placement of drains in
abdominal surgeries
• Prophylactic drainage of the abdominal cavity
after gastro-intestinal surgery is widely used.
The rationale is that intra-abdominal drainage
enhances early detection of complications
(gastro-intestinal leakage, hemorrhage, bile
leak), prevents collection of fluid or pus,
reduces morbidity and mortality, and
decreases the duration of hospital stay.
• A STUDY was performed a systematic literature
search of PubMed and the Cochrane database
from 1990 to 2014. Included in this review were
articles concerning gastric, pancreatic, hepatic
and rectal resections, with comparisons between
the presence or absence of drainage
• CONCLUSIONS OF THE STUDY WERE:
– The policy of routine drainage of the abdominal
cavity in elective gastro-intestinal surgery is currently
under evidence-based scrutiny The interpretation of
the current literature should take into account the
type of surgery and the quality of the studies.
• For gastrectomy, the level of evidence is low-meta-
analysis suggestthere is no necessity to drain for
neithertotal nor partial gastrectomy.
• Concerning pancreatectomy, the data do not allow
recommendation against drainage
• For liver resection, the level of evidence is high:
there is no need to drain the abdomen routinely in
the absence of bilio-intestinal anastomosis.
• As concerns proctectomy, the level of evidence is
low and the analysis does not allow any conclusion
on the utility of pelvic drainage after rectal excision.
• All in all, the literature increasingly suggests that
routine drainage of the abdominal cavity is
obsolete, except in the case of pancreatectomy
where short-term drainage seems to have its
place.
THANK YOU.