Drains

Classification

• Therapeutic
  • Provide egress for established intra-abdominal infection/contamination
  • Control a source of infection that cannot be controlled by more definitive means
• Prophylactic
  • Prevent recurrent infection (prevent reaccumulation)
  • Control prospective or expected leakage from a suture line
  • Warn about complications (bleeding/leak)
• Active - connected to a source of suction - tend to block up quickly as fibrin/tissue is drawn into tube
• Passive - 'open system' - stays open longer, but allows contamination from skin

Common indications

• Good indications:
  • High probability of leakage of bile or pancreatic juice
  • Established pus-containing abscess (non-collapsible)
  • Not satisfied with source control
  • Urine leak is expected
  • High-risk UGI anatomosis
  • Expected bleeding - but be very selective
• Specifically:
  • Draining an anastomosis: J-P drain
  • Lap chole: Leave a drain only if worried about unsolved or potential bile leak. 14-16Fr Blakes likely connected to Bellovac.
  • Appendix - almost never indicated, given source control has been achieved and peritoneal toilet has been performed
  • Perf DU - not unless you are worried about the quality of repair
  • Emergency left colon resection - unnecessary
  • Generalised peritonitis - do not drain unless there is a defined rigid cavity, or a controlled fistula is required

Suturing in place

• I think the Roman sandal method is most secure
• Security can be increased by plastic ties or steristrips around the Roman sandal

Draining an intra-abdominal abscess

• If there's an established abscess with rigid walls, need to leave a long-term drain (2-5 weeks)
• Can do a tubogram prior to removal - once the cavity is no longer significantly larger in diameter than the drainage tract, it can be removed

Closed suction:

Bellovac: closed, active drain system. Negative pressure about 90mmHg and a reservoir of 220mL.

Exudrain: closed, active drain system. Negative pressure about 75mmHg and a reservoir of 100mL.

Redivac/Surimex Fixvac: closed, active drain system. Negative pressure about 338mmHg. Reservoir of 600mL, but note the bottle will only half fill, and will need to be emptied regularly.

Jackson-Pratt: typically connects to this, which is a closed, active drain system with variable negative pressure a reservoir of 100mL. Inverse relationship between reservoir contents and level of suction - suction pressure decreases as the bottle fills.

• To empty: kink tube proximal to bottle; release plug on bulb; squeeze out contents; ensure bulb remains compressed and replace plug.
• Don't leave fenestrated closed suction drains in the abdomen for longer than 10 days - can get tissue ingrowth

Free drainage: closed, passive drainage system, with no negative pressure.

Penrose: open, passive drain with collapsible walls. Will form a well-established tract in 8-10 days if left alone. Ensure to bring it out in a straight line - if there are wrinkles, stagnant pools of fluid will accumulate around the wrinkles. Ideally, place it so that gravity can assist drainage.

Pigtail: closed, passive drain.

Silastic

• Non-reactive - so won't form a tract to outside
• Therefore not useful for draining bile

Problems:

• Lost suction
  • Check for leaks
• Exudate on op-site at skin
  • If needing to change more than twice in 24 hours, change to a polyurethane foam dressing (Biotain) at skin
  • Consider change to coloplast bag
• Shortening drain
  • Cut drain tube about 10cm clear of skin
  • Remove suture and pull out about 2cm
  • Insert a safety pin through drain
  • Place drain in coloplast bag
• Cut and bag drain
  • Difference between cut and bagging and shortening is that the sutures are left in situ and the drain is not withdrawn
• Blocked drain
  • Strip
  • Can flush with sterile technique and a small amount of saline if needed, especially to keep small-calibre tubes open