SURGICAL DRAINS

REFERENCES

1. Davey, A. and Ince, C.S., (2000). Fundamentals of Operating Department

Practice. London: GMM. p264-265.
2. Brooks, A., Mahoney, P. and Rowlands, B., (2008). ABC of Tubes, Drains,
Lines and Frames. Singapore: Wiley-Blackwell, p44-48
3. Kingsnorth, A., and Majid, A., (2001). Principles of Surgical Practice.
London: GMM. p16-18.
4. Kirk, R.M., (1989). Basic Surgical Techniques. 3rd edition. London:
Churchill Livingstone. p251-270
5. Tulloh, B. and Lee, D., (2007). Foundations of Operative Surgery. 1st
edition. Oxford University Press. P132-137
6. TS Venkatachalapathy, TB Nagendra, PN Sreeramulu A Simple Syringe
Suction Drain for Surgical Procedures. Venkatachalapathy et al., J Clin
Case Rep 2012, 2:15
7. R Durai, Surgical Vacuum Drains: Types, Uses, and Complications, AORN
Journal February 2010 Vol 91 No 2
8. Effect of negative pressure wound therapy on wound healing
Current Problems in Surgery51(2014)301–331

CONTENTS
 Introduction
 Classification
 Principles
 Materials
 HOW & WHERE to put a drain?
 Daily Drain Drill (DRAIN)
 Complications
 Removal of Drain
 INTRODUCTION

A drain is a mechanical conduit or device that allows fluid or gas to flow from a
body space cavity to the outside of the body. In other word, drain is used to
prevent collection of fluid in a cavity or a closed space.
The fluid can be PUS, BLOOD, SERUM, URINE, BILIARY OR PANCREATIC
SECRETIONS, INTESTINAL CONTENTS, LYMPH OR AIR

INDICATION
In general, surgical drains are inserted for:
1. Postoperative Drainage
 Drainage of infective focus (abscess cavity, infected cyst)
 To collapse dead space after extensive dissection and elevation of
skin flaps
 To detect anastomotic leak or bleeding
 To assist re-expansion of lungsafter pulmonary lobectomy
 To aid healing eg. bladder surgery, urethral repair, oesophageal
surgery

2. Therapeutic Drainage
 For drainage in pneumothorax, haemothorax or pyothorax
 For intestinal obstruction or ileus
 For percutaneousdrainage of deep abscesses
 For acuteretention of urine

3. Prophylactic Drainage
 Post thoracic surgery - use of chest tube for patients with fractured
ribs requiring assisted ventilation
 Post abdominal surgery - Caecostomy tube after colonic resection
 Use of nasogastric suction for anticipated postoperative ileus
 TYPES OF SURGICAL DRAINS

DRAINS

OPEN CLOSED

ACTIVE PASSIVE

Re-divac PTBD
PENROSE CORRUGATED
GAUZE NPWT T –Tube
YEATES URINARY CATHETHER
JP
INTERCOSTAL CATHETER
Blake
(CHEST TUBE)
Bellovac
 OPEN DRAIN
 Drains into dressings
 This drain is taken out through the main operative wound or via a
separate stab wound stitched to the skin or secured by safety pin
mainly for Penrose/Corrugated drain
 This is then covered by surgical dressing pad
 Do not employ suction
 Mechanism: capillary action
 This type of drain increases the incidence of wound infection and
disseminates infection to other surgical patients in the ward

 Example :
Simple Wicks
Penrose Drain
Corrugated Drain
Yeates Drain

Drain can be made of :

1. Latex rubber : soft but excites a profound inflammatory reaction within
24 hours and renders them totally ineffective
2. PVC : it is much less reactive and more efficient. It is firm and more
unyielding but tends to harden with prolonged use especially it comes to
contact with bile
3. Silicon : it is best material for drains because it is least reactive, more
pliable and does not get hardened with prolonged use
 SIMPLE WICKS CORRUGATED DRAIN YEATES DRAIN PENROSE DRAIN
 Sterile cotton gauze  Can be used for deep &  Similar in nature to the  Consists of a thin-walled
inserted into a cavity or superficial drainage corrugated drain with rubber tube containing a
shallow wound  Should be sutured in similar indications but fine length of gauze.
 Fluid will track along the position consists of a series of  Rubber causes a tissue
material  Induces very little tissue 2mm diameter capillary reaction and the drain
 Gauze act as by capillary reaction tubes track caused by this
action, soaking up material
secretion  Not as rigid as a
 Require changing on a corrugated or Yeates drain
regular basis & may
interfere with granulation
tissue formation
 May lead to pain and
bleeding during removal
 CLOSED DRAIN

 Drainage into containers, which may be active or passive.

 Mechanism:
Drainage by gravity (close siphon drain)  PASSIVE DRAIN
 Tube drains connected to drainage bag
 The drainage bag has a one way valve at the entrance and a
drainage tap at the opposite end
 The tap allows daily emptying without disconnection
 Using natural pressure differences between the body and the
exterior

Drainage by suction (close suction drain)  ACTIVE DRAIN

 In this system, firm polyethylene tubes are connected to
portable suction devices
 Some devices utilize low pressure vaccum (-100 to -150
mmHg) eg: JP/Bellovac
 Others utilize high pressure negative suction (-300 to -500
mmHg) eg: Redivac
 Closed Drain: Active
 Connected to a suction source/vacuum creating a continuous pressure difference between proximal & distal end of
the drain
 Negative pressure causes:
Continuous wound cleaning thereby decrease the bacterial burden in the wound, remove substances that inhibit
wound healing, promotes continuous removal of fluid like exudates so that prevents the mechanical compression by
accumulated exudates into the capillaries at the site of restricts flow of blood into wound site.
 They can be under low or high pressure
 High negative pressure, eg : Redi-vac
 Low negative pressure, eg : Jackson Pratt, Bellovac

HIGH NEGATIVE PRESSURE DRAINS LOW NEGATIVE PRESSURE DRAINS

 Sealed and closed circuit drain system (bottled  Have a plastic bulb-shaped reservoir or spring
vaccum system) that are easily monitored and allow reservoir and a drainage tube (JP or Bellovac) with
safe disposal of the drainage multiple side holes in the end of the tubing that is
 It consist of clear, plastic/bottled reservoir with a inserted into the wound
rubber cap and indicator wings that monitor the  When the bulb is compressed, air is forced out which
presence of vaccum pressure and an opening in create low negative pressure to evacuate excess fluid
which the drainage tube connects and air gently
 When vaccum is present in the system, the wings on
the rubber cap are close together, when the vaccum
is lost, the wings are apart
 The end of the drainage tube inserted in the wound
has numerous openings to evacuate fluid from the
wound
 Wound should be closed before opening the clamps
on the drain or else the vaccum will be lost
Re-divac/Hemovac Drain Jackson-Pratt Drain Bellovac
 Also called JP drain/bulb
drain
 Flexible plastic tube which
connects to an internal
plastic drainage tube, and
it drains excess fluid by
constant low suctioning
 Due to low pressure
vaccum system,
intraabdominal content
will not get sucked
through the drain thus
preventing possibility of
ischemia
 Air pressure within the
drainage system is
removed by removing the
plug and squeezing the
bulb
VAC/MDWT/NPWT

General system consist is made up of 4 major components :

 Filler material or sponge placed into the wound
 Semipermeable dressing to isolate wound
environment and allow the vaccum system to
transmit subatmospheric pressure to the wound
surface
 Connecting tube and fluid collection canister
 Vaccum system
Mechanism of Action (primary effects) Macrodeformation
 Refers to induced wound shrinkage caused by
1. Macrodeformation collapse of the pores and centripetal forces exerted
2. Microdeformation onto the wound surface by the foam
3. Fluid removal Microdeformation
4. Alteration of the wound environment  Refers to the undulated wound surface induced by
porous interface material when exposed to suction
 Variety mechanical forces (shear and hydrostatic
pressure from ECM, stretch and compression from
surrounding matrix and gravity pull) transmitted to
the cell by combination of suction and counteracting
downward of sponge strut.
Fluid removal
 Removal of fluid from extracellular space
 Thus reducing tissue edema and increased lymphatic
drainage from the wound
Alteration of wound environment
 Fluid removal is an important element in achieving a
wound environment conducive to healing
 The foam and semiocclusive drape act as thermal
insulators by maintaining wound warmth
 Semiocclusive PU drape is fundamental in
maintaining subatmospheric pressure at wound bed
and prevent evopartive water loss
 Dressing is impermeable to proteins and
microorganism (reduce risk of infection)
 The drape exhibits limit permeability to water vapor
and other gases, helping maintain a stable moist
wound environment.
 How About This?
What Type of Drain?
Usefulness?

 The scalp vein set (wing or butterfly needle) can be used as a continuous
suction drain.
 It needs to be connected to a 10 ml syringe and 2 cc syringe piston to
maintain negative suction.
 Apart from it, small pieces of scalp vein can be used as Penrose type tube
drains for suture site
 Scalp vein set can be used for multiple procedures in plastic surgery:
o Saline infusion and removal from tissue expander
o Penrose type tube drain in wound margins
o Continuous suction drain and Irrigation of wound
o Tourniquet for finger, penis.
o Dye injection in sinus/fistula to delineate cavity/tract.
o Soft cover over cut K-wire used after fracture fixation of digits
o For venipuncture
 Closed Drain: Passive

 Dependent on gravity (siphon effect) & the pressure differential between

body cavity & the exterior

Siphon Effect
A liquid to flow, above the surface of a
reservoir, with no pump, but powered by
the fall of the liquid as it flows down the
tube under the pull of gravity, then
discharging at a level lower than the surface
of the reservoir from which it came

Example :
Pig Tail Catheter- Percutaneous Transhepatic Biliary Drains
T –Tube
Urinary Catheter
Intercostal Catheter
NG tube
T-Tube

 Consists of a stem and a cross head.

 The cross head isplaced into the common bile duct while the stem is
connected to a small pouch.
 Used as a temporary post-operative drainage of CBD.
 Advantages vs Disadvantages
Active Drains

Advantages Disadvantages
Keep wound dry- efficient fluid High negative pressure may injure
removal tissue
Can be placed anywhere Drain clogged by tissue
Prevent bacterial ascension
Help appose skin to wound bed-
quicker wound healing
Allows evaluation of volume and
nature of fluid

Advantages vs Disadvantages
Passive Drains
Advantages Disadvantages
Allow evaluation of volume and Gravity dependent- affects location of
nature of fluid drain
Prevent bacterial ascension Drain easily clogged
Eliminate dead space
Help appose skin to wound bed-
quicker wound healing
 PRINCIPLES

 Must not be too rigid

 Must not be too soft
 Not of irritant material
 Wide bore enough to function
 Left for sufficient time so that when drain removed there is minimal
drainage
 When used prophylactically e.g. duodenal stump or anastomotic leak, the
drain should be left in situ as long as the danger of perforation exists, i.e.
for 10 days, until a fibrous track is formed which will act as an external
fistula (with a safety-valve action).
 To minimize the infection rate: drain from a separate wound, use closed
system and the shortest duration used.

HOW & WHERE to put a drain ?

 Sites of collection
 Tip should be free in the cavity to be drained
 Tip should not be in contact with vital
structures/vessels/nerve/anastomosis/across joint
 Brought out through separate stab incision which should permit free
drainage
 Most dependent drainage
 Brought out by the shortest route
 Route should not be tortuous
 Firmly anchored to skin
Drain can be placed in following anatomical spaces or planes:
1. Subcutaneous plane :
Drains are inserted below flaps to take care of dead space where there is
chances of blood collection in this space. Common indications are after
thyroid surgery, after mastectomy, and ventral hernia repair

2. Intramuscular plane :
After surgery for soft tissue sarcoma

3. After drainage of abscess :

A drain is put in the residual cavity which prevents the premature closure of
opening of abscess cavity and allows abscess cavity to heal from below

4. In the pleural cavity :

To drain blood, pus, air or infected fluid

5. In the peritoneal cavity :

After surgery for peritonitis, after major resection

6. In the retroperitoneal space :

After renal surgery/removal of retroperitoneal tumor

7. In the retro pubic space :

To drain urine after bladder surgery, after open prostate removal

Daily Drain Drill (DRAIN):

 Daily volumes & types of fluid drained

 Re-securing drain if loose or displaced
 Adequate suction (if applicable)
 Is it blocked, kinked, or leaking?
 Need for removal
 COMPLICATIONS

Drain placement Drain residence After removal

 Damage to nearby  Leakage & skin  Re-accumulation of
structures excoriation collection
 Bleeding  Infection via drain  Herniation at drain site
track  Scar formation
 Damage to
anastomosis
 Retraction into the
wound
 Pain at drain site
 Displacement of drain
 Decreased patient
mobility

REMOVAL OF DRAIN

 Absolute rules do not exist but optimum time for removal depends
primarily on the :
Reason for insertion in the first place
Character
Volume

 Drains can be ‘shortened’ by withdrawing by approximately 2cm per day,

allowing the site to heal gradually.
 Drain that protect post- operative sites from leakage form a tract and are
usually kept in place for one week.