Drainage system in abdominal surgery

A. Thangamani ramalingam

PT, MSc (PSY), MIAP

Drains & tubes

Definition

A surgical drain is a tube used to remove pus, blood or other fluids from a wound.

A drainage tube is usually only used in extreme medical situations when the patient is at greater risk of having complications from a collection of fluid around an organ, over the risk of inserting a drainage tube.

used for short periods

WHY

To reduce the risk of haematoma formation and break down of wound

an excessive amount of blood and fluid that collects in the cavities of the body, and around organs

faster wound healing or prevent infection

Disadvantages

Presence of a drain increases the risk of infection

Damage may be caused by mechanical pressure or suction

Drains may induce an anastomotic leak Most drains abdominal drains infective

within 24 hours

Principles Septic wounds should be drained Aseptic wounds those having oozing vessels

or large area Wounds with chances of more fluid collection

inside Leaking wounds from anastomosis

Unless there is a definite reason, the drainage should be removed with in 48 hrs

Types of Drainage Tubes

Open or closedActive or passive Tube drains Corrugated drains

Open drains Include corrugated rubber or plastic sheets Drain fluid collects in gauze pad or stoma bag They increase the risk of infection

Closed drains Consist of tubes draining into a bag or bottle They include chest and abdominal drains The risk of infection is reduced

Active drains Active drains are maintained under suction They can be under low or high pressure

Passive drains Passive drains have no suction Function by the differential pressure between

body cavities and the exterior

Types of drainage systems

The closed drainage system is a system of tubing or other apparatus that is attached to the body to remove fluids in an airtight circuit that prevents any type of environmental contaminants from entering the wound or area being drained.

The open drainage system is a tube or apparatus that is

inserted into the body and drains out onto a dressing. Lastly the suction drainage system uses a pump or

mechanical device to help pull the excessive fluid from the body.

Jackson-Pratt drain- closed drainage system / uses suction

consists of a tube connected to a see-through collection bulb. The bulb has a drainage port which can be opened to remove fluid or air so that the bulb can be squeezed to create suction. The drain is placed below the area of the wound.

Common uses Abdominal surgery Breast surgery Mastectomy Thoracic surgery

Penrose drain-open drainage

A Penrose drain is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid.

It is named for the American gynecologist Charles Bingham Penrose (1862–1925)

Redivac drain/Hemovac drain is a closed/suction drainage system

Pigtail drain - has an exterior screw to release the internal "pigtail" before it can be removed

Davol Chest tube Wound manager Cigarette drain

T-Tube drain

T-Tube drain is used for mostly for patients who have undergone gallbladder surgery or surgery of the surrounding tubes draining the gallbladder. This type of drainage most resembles a T and drains into a collection bag.

Nasogastric tubes

Following abdominal surgery gastointestinal motility is reduced for a variable period of time

Gastrointestinal secretions accumulate in stoma and proximal small bowel

May result in: Postoperative distension and vomiting Aspiration pneumonia

Little clinical evidence is available to support the routine use of nasogastric tubes

May increase the risk of pulmonary complications Of proven value for gastrointestinal decompression in intestinal

obstruction Tubes are usually left on free drainage Can be  also aspirated maybe every 4 hours Can be removed when volume of nasogastric aspirate is reduced

IV lines To maintain electrolyte balance To ensure nutrition and hydration

Urinary catheters

A urinary catheter is a form of drain Commonly used to:

Alleviate or prevent urinary retention Monitor urine output

Can be inserted transurethrally or suprapubically

The material from which they are made (latex, plastic, silastic, teflon-coated)

The length of the catheter (38 cm 'male' or '22 cm 'female')

The diameter of the catheter (10 Fr to 24 Fr) The number of channels (two or  three) The size of the balloon ( 5ml to 30 ml) The shape of the tip

Special catheters

Gibbon catheters Nelaton catheters Tiemann catheters Malecot catheters

Complications

Paraphimosis Blockage By-passing Infection Failure of balloon to deflate Urethral strictures

breast drain

Abdominal incisions

Abdominal incisions are based on anatomical principles They must allow adequate assess to the abdomen They should be capable of being extended if required Ideally muscle fibers should be split rather than cut Nerves should not be divided The rectus muscle has a segmental nerve supply It can be cut transversely without weakening a denervated

segment Above the umbilicus tendinous intersections prevent retraction of

the muscle

Midline incisions are the commonest approach to the abdomen

The following structures are divided: Skin Linea alba Transversalis fascia Extraperitoneal fat Peritoneum

The incision can be extended by cutting through or around the umbilicus

Above the umbilicus the Falciform ligament should be avoided

The bladder can be accessed via an extraperitoneal approach through the space of Retzius

The wound can be closed using a mass closure technique

The most popular sutures are either non-absorbable or absorbable monofilaments

At least 1 cm bits should be taken 1 cm apart

Requires the use of one or more sutures four times the wound length

Paramedian incision • A paramedian incision is

made parallel to and approximately 3 cm from the midline

• The incision transverse: o Skin o Anterior rectus sheath o Rectus - retracted laterally o Posterior rectus sheath -

above the arcuate line o Transversalis fascia o Extraperitoneal fat o Peritoneum • The potential advantages

of this incision are: o The rectus muscle is not

divided o The incisions in the

anterior and posterior rectus sheath are separated by muscle

• The incision is closed in layers

• Takes longer to make and close

• Had a lower incidence of incisional hernia (when sutures were not so good)

Closure of incision

Ambroise Paré (1520-1590)

Paré was an astute observer and brought many innovations to surgery and wound care. One of the most important concepts he introduced was that wounds should be treated gently to reduce inflammation and promote healing. For a significant part of his career Ambroise Paré was a barber surgeon in the army of the king of France. He abandoned the traditional treatment of cauterizing wound after his experience in the battle of Turin in 1536, when the French fought the Italians.

Ligature and suture materials

Absorbable Non-absorbable

Absorbable materials

1. Catgut plain – used to suture mucous membrane of lips, tongues superficial laceration of the genital area. They are easily absorbed within one week.

2. Catgut chromic – used to suture fascia, muscles, or ligature of blood vessels.It is usually absorbed within 30 – 45 days

3. vicryl – same as above. Takes at least 70 days for absorption. Rapid vicryl is easily absorbed.

4. PDS – expensive, takes at least 5 – 6 months to be absorbed.

Absorbable suture materials are those that are broken down. The original absorbable suture materials were plain and chromic “cat gut,” which actually consisted of processed collagen derived from the submucosa of animal intestines. Plain gut is broken down enzymatically after about 7 days. Chromic gut is collagen treated with chromium salts to delay break down. Chromic gut typically loses its strength after 2-3 weeks is completely digested after about 3 months.

Now there are many synthetic absorbable materials made from polymers (e.g., Vicryl and Monocryl). These materials are broken down non-enzymatically by hydrolysis; water penetrates the suture filaments and causes breakdown of the polymer chain. As a result, synthetic absorbables tend to evoke less tissue reaction than plain or chromic gut.

Non-absorbable materials

1. Ethilon – most commonly used to close and suture skin after surgery or trauma to the skin. Cutting needles are usually used.

2. Prolene – used to suture nerve, tendon or blood vessels. Preferable round body needles are used.

3. Silk and Linen – have similar properties. They are very strong, but they are adherent to the tissues and can caused reaction or infection.

Non-absorbable sutures are made of materials that are not readily broken down by the body’s enzymes or by hydrolysis. There are naturally occurring non-absorbable materials e.g., silk, cotton, and steel)

synthetic non-absorbable materials (e.g., nylon and Prolene, Mersilene). In some cases they are left in place indefinitely (e.g., when used to close the abdominal fascia), and in other cases they are removed after adequate healing has occurred (e.g., nylon sutures to close a superficial laceration).

Other suture materials

1. Staples – to close wound under high tension, like scalp, trunk and extremities.

2. Strips and tapes – used to close superficial laceration on the face.

3. Derma bond – very expensive, ideal for simple laceration, but fact around the edges have to be removed.

Types of sutures/ METHODS OF METHODS OF SUTURINGSUTURING

Simple interrupted suture Vertical mattress Horizontal mattress Subcuticular Continuous

NeedlesNeedles may also be classified by their point

geometry; examples include:

taper (needle body is round and tapers smoothly to a point)

cutting (needle body is triangular and has a sharpened cutting edge on the inside)

reverse cutting (cutting edge on the outside) trocar point or taper cut (needle body is round and

tapered, but ends in a small triangular cutting point) blunt points for sewing friable tissues side cutting or spatula points (flat on top and bottom

with a cutting edge along the front to one side) for eye surgery

Types of knots 1Yarnknot  2Manrope knot 3Granny knot 4Rosebud stopper knot 5Matthew Walker's knot 6Shroud knot 7Turks head knot 8Overhand knot Figure-

of-eight knot 9Reef knot Square knot 10Two half hitches

Suture removal

sutures are normally removed after Face and head ……………. 5 days Legs and abdomen ………. 7 – 10 days Back and soles …………… 10 – 14 days

When?

Face: 3-4 daysScalp: 5 daysTrunk: 7 daysArm or leg: 7-10 daysFoot 10-14 days

How?          Many patients are very apprehensive about suture removal, so the first step is to reassure the patient that the procedure is not painful. The skin should be cleansed. Hydrogen peroxide is a good choice for gently removing dried blood and exudates. 

THANK YOU