To drain or not? The role of drainage in emergency abdominal surgery: international and personal perspective (translation)

In order for the wound surface to shrink faster, it is necessary to create favorable conditions for the regenerative process to occur. They can be ensured by wound drainage performed in a manner appropriate to the type of injury. It is not always performed, but only according to the surgeon’s indications. Based on modern medical concepts, the drainage process, depending on what type was chosen, should clear the damaged surface of blood clots, thereby eliminating the possibility of infection and the entry of pathogenic microorganisms into the wound.

Manipulation helps to tightly connect the separated wound surfaces, thus stopping capillary and vascular bleeding and to clean and disinfect the damage before applying a bandage. Wound drainage is a therapeutic and prophylactic technique used in surgery to create an unfavorable environment for the development of infectious infection in the wound by maintaining the removal of discharge from the damaged area and monitoring the healing process.

Moshe Shine

The history of abdominal drainage is as old as surgery itself (1). However, abdominal drainage is still a subject of debate and constant discussion. Even 100 years ago there were passionate proponents of drainage, like Robert Lawson Tait (1845-1899), who said: “When in doubt, drain!” There were also skeptics, like JL Yates (1905), who said: “Drainage in general peritonitis is physically and physiologically impossible”! There were also those like Joseph Price (1853-1911): “There are people who ardently defend drainage, and there are those who categorically deny it. Both are right in their own way.”

100 years have passed, during which operative surgery and supportive care have progressed continuously. But what about drainage? Are there fewer discussions and contradictions today? What awaits drainage tomorrow?

In this short post I try to answer these questions from the perspective of drainage for abdominal and abdominal infections. Elective surgeries will be mentioned only as part of the discussion. Percutaneous drainage, both primary and postoperative, is outside of our discussion.

Drainage classification

Drains are installed for therapeutic or preventive reasons.

Medicinal:

• To ensure the outflow of intra-abdominal fluid or pus (periapendicular abscess, diffuse peritonitis).
• To control the source of infection if it is impossible to remove it by other, radical methods; for example, with an external intestinal fistula (duodenal stump).
• Preventive:
• To prevent recurrence of infection - to evacuate residual serous fluid or blood, prevent the formation of an abscess.
• To monitor expected or probable leakage from the suture line (colic anastomosis, duodenal stump, cystic duct).
• To report complications (in the hope that drainage will work in case of bleeding or leakage of chyme from the anastomosis).

It is better, rather than discussing a rigid classification, to look at the problem of drainage through the eyes of a general surgeon. What are the common tactics? What is the practice for general surgery?

The literature is a poor source of information about how common abdominal drainage is in emergency surgery. Analyzing several publications from individual clinics or collective reviews on drainage for specific conditions, we cannot draw a conclusion about the dominant trends. Therefore, we present the opinions of general surgeons - members of SURGINET - and the results of an international Internet discussion (2) regarding their views on abdominal drainage. Of the 700 members, only 70 responded. Although this is quite small, it correlates with the frequency of Internet responses received for any online survey.

The survey involved 71 respondents, all general surgeons, many of them not academic specialists, but earning their bread and butter through practical work, from a total of 23 countries. Most of all (14) are from the USA, and in total from North America - 18, Western Europe - 10, Eastern Europe - 7, Asia - 15, including Israel and Turkey; Latin America – 15, Australia and South Africa – 3 each.

Surgeons who are active in the Internet survey are, as a rule, more interested, active, and familiar with the literature and modern practice in other activities. The survey results reflect inconsistencies and geographic differences in their surgical practices.

Common situations where drainage may be used

Indications

Drainage is installed if it is necessary to ensure the outflow of transudate discharged from the wound into the external environment. Drainage is necessary if there is inflammation of an infectious nature or conditions that cause the wound surface to become inflamed and pus to appear in it.

The technique is also used when it is necessary to remove localized accumulations of blood clots, lymph, purulent and bile secretions from a damaged surface and in order to control the regeneration process. In addition, surgeons often resort to drainage if there is a risk of bleeding after surgery.

Acute appendicitis

In table Figures 1 and 2 summarize the surgeons' responses. “Simple” or “phlegmonous” appendicitis was excluded. Only complicated forms are discussed: when the appendix is ​​black, there is usually some fluid in the pelvis, but it is not obvious pus. As follows from the table. 1, only one respondent drains the cavity in this situation. Next, when the appendix is ​​perforated, a laparotomic or laparoscopic surgeon removes the appendix and sucks out the pus present around the appendix. In these cases, the surgeon can destroy the barrier of the omentum or loops of the small intestine, exposing a small abscess of a few cubic millimeters, and the pus is also aspirated. Table 2 shows that 80% of respondents do not install drainage in this situation. However, there is no geographical pattern. Table Figure 3 illustrates advanced cases where perforated appendicitis is combined with a “pus everywhere” situation - in the pelvis, along the right lateral canal, even in the upper floor. And, although 80% of surgeons do not install drainage in this situation, there is a geographic dependence: they never or almost never drain the abdominal cavity in North and Latin America, and quite often in the Asian world. This depends on how the surgeon views the role of drainage in the treatment of diffuse peritonitis; complications will be discussed later.

Table 1. Do you place drainage after appendectomy for gangrenous appendicitis?

Table 2. Do you place drainage for perforated appendicitis, when there is little pus and it is present locally?

Table 3. Do you place drainage for perforated appendicitis with diffuse spread of pus?

Drainage for acute appendicitis

In 1979, O'Connor and Hugh, in an excellent review, concluded: “Intraperitoneal drainage is of little value in phlegmonous, gangrenous, or perforated appendicitis. However, drainage is indicated if there is a limited purulent cavity or a gangrenous stump that is imperfectly closed” (1).

I will not overwhelm you with details of all the available literature, since Petrowsky et al. recently released an excellent analysis of these studies (3). After presenting individual studies, including their own meta-analysis, the authors concluded that “drainage does not reduce the incidence of postoperative complications, and even appears to be harmful in terms of the formation of intestinal fistulas (the latter was observed only in drained patients). Drainage should be avoided in any form of appendicitis” (4).

Drainage after appendectomy for phlegmonous and gangrenous appendicitis is not needed. Most surgeons who took part in the survey understand this. What is said about perforated appendicitis with local formation of a purulent focus? Of our respondents, 22% will install drainage. As will be shown below, a “formed” or “unopened” abscess, according to most surgeons, is a good indication for installing drainage. But an abscess against the background of perforated appendicitis is not “unopened”: after the surgeon destroys its wall and evacuates the pus, the potential abscess space is filled with nearby loops of intestine, mesentery and omentum. Thus, the source of infection is removed, the abdominal cavity is cleaned by toileting. The peritoneal defense mechanism is then activated, supported by a short course of antibiotics, with complete eradication of bacteria without the presence of an irritating foreign body (4).

Uncertain closure of the appendiceal stump as a justification for drainage seems anachronistic. Safe closure is possible even in rare cases where perforation occurs at the base of the appendix, by placing a suture or stapler on the dome of the cecum.

Of our respondents, 23% use drainage for appendicitis complicated by diffuse peritonitis. However, as will become clear later, these are the same surgeons who advocate drainage for generalized intra-abdominal infection. And drainage in this situation - after controlling the source of infection - seems useless.

Principles of staging

The basic principles of drainage installation are presented:

• Installation of drainage systems in the sloping area of ​​the wound cavity.
• Fixing the drainage device.
• By creating such conditions that the drainage does not come into contact with important anatomical formations, represented by nerve endings, vascular network and tendon apparatus.
• Minimizing complications after the procedure.
• Preventing depressurization of the wound cavity and compression of tissues with their damage.
• Minimizing the penetration of pathogenic microorganisms into the cavity through drainage tubes.

Acute cholecystitis

Nowadays, the surgeon often performs “difficult” laparoscopic cholecystectomy (LCE) in patients with advanced acute cholecystitis. The preparation is not easy, the time is considerable, and the discharge from the liver causes outrage. To complete the procedure, a transition to laparotomy is possible. The question remains: is it reasonable to leave drainage in the area of ​​the gallbladder bed or under the liver? A third of respondents will answer “YES” (Table 4). Please note that the emphasis in the question was on the expression “routine drainage”. Many respondents leave it selectively, in case of unfavorable closure of the cystic stump or in anticipation of active exudation.

Table 4. Do you place drainage after open cholecystectomy (OCE) or LCE for severe acute cholecystitis?

Drainage after cholecystectomy for acute cholecystitis

A large prospective randomized study in 1991 and a meta-analysis of 1920 patients (ACA) summarized 10 similar studies. It was shown that when comparing patients with and without drainage in terms of mortality, reoperation or drainage due to bile accumulation, there were no differences. Wound infection more often accompanied patients with drainage (5). Thus, on the eve of the end of the era of BCI, routine drainage - the sacred cow of biliary surgery - was abandoned in many centers.

What is the trend in emergency LCE? In a recent study of Australian surgeons, drainage was left routinely in 1/3 of cases (6). Another small randomized trial comparing patients with and without drainage for LCE examined the effect of drainage on postoperative pain and nausea, in terms of gas removal, and found no difference (7). If routine drainage is pointless in ACE, why is it indicated in LCE? Therefore, Petrowsky et al. (3) drainage is not recommended for both ACE and LCE. In a prospective study of 100 patients who underwent LCE for acute cholecystitis, all of them underwent cholescintigraphy one day after surgery. Bile leakage was detected in 8, but all of them were asymptomatic (8). Most postoperative collections, be it bile, serous fluid or blood, remain asymptomatic, the fluid is absorbed by the peritoneum and this is well known from ultrasound studies since the time of AChE.

Drainage is much more effective at removing bile than stool or pus. Therefore, it is logical to leave a drain if the surgeon is concerned about possible bile leakage. For example, if a subtotal cholecystectomy is necessary, or when there are difficulties with sealing the cystic duct, or there is a suspicion of additional bile ducts in the area of ​​the gallbladder bed, which manifests itself in the form of bile leakage from the surface of the bed.

Thus, although most patients do not require drainage, if the surgeon is concerned about possible bile leakage or excessive serous fluid, drainage is appropriate. In most cases, almost nothing is separated through such drainage. It is extremely rare that preventive drainage becomes therapeutic in the case of profuse and persistent bile leakage. In cases where the need for an existing drain is questionable, it is extremely important to remove it as soon as possible. “Dry” drainage for 24 hours indicates that it has served its role. Finally, Howard Kelly (1858-1943) said: “Drainage is the recognition of defective surgery.” Clinicians must be careful not to confirm this statement in practice: if it is safer to switch to an open procedure and carefully close the ultrashort cystic duct than to rely on questionable clip closure and safety drainage, then the choice is clear.

Peculiarities

Wounds, especially those with a purulent etiology, need proper therapy. In order for the cavity to heal faster and the pus to disappear completely, it is necessary to install drainage.

Drainage is divided into types. If the patient is in a supine state, then the drainage system is installed at the lowest point so that the contents from the cavity flow out independently under the force of gravity.

Passive drainage can also be used. It will absorb the liquid contents of the wound. But since it is weakly effective, it is used infrequently.

With the help of active drainage, the wound can be treated with antiseptic and anti-inflammatory drugs, and the purulent contents can be removed mechanically.

Drainage can be made of plastic, glass, rubber and gauze. The device most often has different sizes and diameters, selected based on the depth, width and type of wound.

For drainage to be effective, it must be selected individually for each wound surface. It also needs to be positioned correctly, and the materials for its creation must be selected so that they correspond to the sensitivity of the microflora.

Drainage of cavities is carried out during the inflammatory process. Once the cavity is cleaned and begins to heal, the drainage must be removed. It is also worth removing the device when an inflammatory process begins around it.

When installing drainage, it is necessary to observe all aseptic measures, since through drainage tubes or holes, not only transudate can escape, but also pathogenic microorganisms can enter the wound cavity.

Failure to install drainage will lead to accumulation of transudate in the cavity. The wound healing process always depends on many factors and, in the absence of a drainage device, can lead to an inflammatory purulent process.

If it starts, or a hematoma forms in the wound, the scar will take much longer to form, and healing will be more difficult. It is for this reason that if there are indications for drainage, you should not refuse it. Don't risk your health and always follow your doctor's orders.

Drainage after omentopexy for perforated ulcer

If you have performed perfect suturing of a perforated ulcer with tomponade with an omentum, is drainage necessary? 80% of respondents said “no” (Table 5).

Table 5. Will you leave drainage after suturing a perforated ulcer with tomponade with a strand of omentum?

Literature data is limited. Pai et al. [] in their message are the most informative. In the treatment of peritonitis, multiple drainage does not reduce the incidence of intra-abdominal fluid accumulation and abscess formation, nor does it improve postoperative results. Depressurization of the sutured hole was observed in 4 patients with drainage (5.3%) and 1 without drainage (2.3%). They all died. The wound around the drainage festered in 10% of patients. One required laparotomy to free a loop of small intestine that was twisted around a tube. Another developed bleeding from a drainage hole. Based on their own experience and literature data, Petrowsky at al found that “suturing a perforated ulcer with tomponade with an omentum is safe without prophylactic drainage; routine drainage cannot be recommended” (3).

Suturing with tomponade with an omentum, properly performed and tested by injecting colored liquid through a probe, prevents leakage. In addition, when leakage develops, the presence of a drain is not helpful (9). Duodenal lateral leakage is a very serious complication and is almost impossible to control with simple drainage. To stop, relaparotomy and gastric resection according to B-2 are indicated. or, at a minimum, transfer of the “side” duodenal fistula to the “end” one (Gastroenteroanastomosis + tubular duodenostomy, or disconnection of the duodenum). Excessive reliance on drainage when leakage has developed delays vital surgery and hastens death.

What can we say about laparoscopic suturing, an increasingly popular procedure? Does this change the indication for drainage? Leakage after omentopexy is so rare that even comparison of very large series of open and laparoscopic operations does not allow reliable conclusions to be drawn. However, surgeons who have used open omentopexy have alarmingly reported leakage rates of 6–16% after laparoscopic closure (10). This may be due to a “learning curve” - the inability to feel the tension of sutures and tissues, in particular the packing omentum. Therefore, the laparoscopic approach may be more prone to leakage from the sutured opening. I'm still amazed when I see drainage being used to prevent disaster. I find this unlikely. A surgeon who knows how to suture safely does not need drainage. But for a surgeon learning laparoscopic closure (with a small number of peptic ulcers, your learning curve can take forever) drainage may be allowed. It will not prevent reoperation if leakage has occurred. But it can provide early diagnosis when leakage requires re-intervention. However, a timely contrast study (with or without CT) will provide more information than an often poorly placed and unproductive drain.

Types

Drains can be represented by strips of latex, made of rubber, silicone, vinyl chloride, fluoroplastic and Teflon. Sometimes drainages made of gauze folded in several layers are also used, but since they have a short operating time, they are used infrequently. Rubber drainage also has shortfalls. It is quickly delimited by fibrin formed in the wound, adhesions of the epidermis and deep tissues in which it is installed.

At the moment, surgeons prefer complex drainage systems, represented by multi-lumen, cuff, rubber-gauze, T-shaped and fan types. The general requirements for drainage are softness, smoothness, strength and transparency of the material. Also, all drains must be radiopaque.

Emergency colon surgery

Issues of drainage after emergency resection of a perforated sigmoid without or with primary anastomosis should be considered together. In both cases, control of the source of infection is provided by colectomy. The reason for drainage can be twofold - therapeutic (to help in the treatment of concomitant intra-abdominal infection) or prophylactic (to prevent the accumulation of fluid or to control the incompetence of the suture line of the anastomosis or rectal stump). About 60% of respondents (Tables 6 and 7) do not routinely drain the abdominal cavity in this situation.

The topic of drainage after left hemicolectomy with or without anastomosis has been discussed for 30 years. Proponents claim that drainage prevents reoperation in case of suture failure. Critics argue that the drainage itself causes failure. It is difficult to determine the validity of the 8 studies by Petrowsky et al. [], which included emergency and elective patients, with and without drainage. All 8 studies showed no difference in postoperative complications with or without drainage, but some authors reported a high incidence of wound infection with drainage. They talk about small advantages of not draining in relation to leakage. This confirms an earlier meta-analysis by Urbach et al. [], who concluded that “there is no significant benefit from routine drainage of intestinal or rectal anastomoses in terms of reducing the incidence of leaks or other complications.” The same authors reported that "20 observed leakages among all 4 studies that occurred in patients with drainage, in only 1 case (5%) did pus or intestinal contents actually appear through the drainage." Even overly cautious authors conclude that “there is insufficient evidence to show that routine drainage of colorectal anastomoses prevents anastomotic or other complications” (12).

Table 6. Do you place a drainage during the Hartmann operation against the background of cancer perforation or sigmoid diverticulum?

Table 7. Do you place drainage during colectomy and primary anastomosis due to cancer perforation or sigmoid diverticulum?

The surgeon decides to drain in this situation for the following reasons:

1. Combating residual or preventing recurrent intra-abdominal infection by removing exudate or draining a peri-intestinal abscess discovered or already drained during the operation. The futility of such drainage in terms of achieving the stated goal has already been discussed in the section on acute appendicitis.

2. Drainage of the area of ​​future possible anastomotic leak. However, the high risk and tendency of the anastomosis to depressurize are circumstances that are not suitable for anastomosis in an emergency situation. In addition, drainage does not help with leakage, not to mention the false sense of security in the absence of discharge through the drain (13). Only a pathological optimist can assume that feces will be released through the drainage and the tube will not become clogged with fibrin. In conclusion: drainage after emergency colon resection is a waste of time.

Drainage for diffuse peritonitis

With diffuse peritonitis, only a third of respondents drain the abdominal cavity (Table 8).

Table 8. Will you drain the abdominal cavity with diffuse peritonitis?

The distribution of answers here is identical to questions 3, 5, 6, 7. Asia and Eastern Europe believe in the value of drainage for local and diffuse intra-abdominal infection. There are no comparative studies of drainage and non-drainage in diffuse peritonitis, since the futility of drainage in this situation was established many years ago by experts in surgical infection. The modern view, presented by the Society for Surgical Infection, is formulated by Rotstein and Meakins []: “It is impossible to drain the abdominal cavity with generalized peritonitis. Therefore, the use of drainage in these patients is not indicated, except in cases where (1) drainage is used for postoperative lavage; (2) drainage is placed in the cavity of a well-confined abscess; (3) drainage is used to form a controlled fistula.”

I remember when I was a junior resident, post-op patients would have rubber drains sticking out of every quadrant of their distended abdomen. These tubes produced some old blood, or perhaps some pus or foul-smelling fluid. When such a patient died, the cause was often given as pneumonia. How stupid we were! We believed that these drainages could be useful! Gradually we came to the understanding that they were worthless: all intra-abdominal drainages became clogged with surrounding tissue within 24-48 hours.

The only indication for the use of drainage for generalized peritonitis is control over an uncontrolled (unremovable) source of infection, such as failure of the duodenal stump or esophagogastroanastomosis. I am skeptical about the term “well-confined abscess” or “formed abscess” as an indication for peritoneal drainage. Such abscesses accumulate pus and are part of diffuse peritonitis. Once evacuated, they should be treated as part of the infected abdomen, along with other peritoneal measures and antibiotic therapy. Of course, peritoneal lavage is a thing of the past.

In conclusion, it is important to understand that drainage for diffuse peritonitis is pointless. However, recurrent or persistent intra-abdominal infection may develop, requiring percutaneous drainage or reoperation. Drainage will not replace this. And the fact that you do not have a CT scan at hand should not change the indication for drainage, as will be shown below.

Medical rubber drainage tube (type-2 for surgical purposes

Medical drainage tube, rubber type-2 - used in medicine for surgical purposes: to remove pathological fluids from cavities or wounds of various sizes for any type of drainage. Can be used for blood transfusion. Drainage tubes after operations are made of high-quality environmentally friendly material. The rubber drainage tube is suitable for any method of temperature disinfection.

Dimensions: Inner diameter: from 4.0 to 12 mm. Wall thickness: from 1.5 to 3.5 mm. Guaranteed shelf life of tubes: – 5 years from the date of manufacture. Warranty life of tube type 2: - no more than 5 sterilizations. Packaging: The rubber drainage tube is wound into a 5.0 kg roll and packed in a cardboard box. Manufacturer: JSC "Alfaplastic Association" , Russia Medical rubber drainage tube (any size) price per package 5 kg:

Obligate drainage

In what situations is drainage necessary? Each respondent answered this question according to his own understanding (Table 9). From a purely practical point of view:

1. In the first place, and this is true, is the possibility of leakage of bile or pancreatic juice. These fluids are easily collected and evacuated by drainage, which, when installed in cases of biliary and pancreatic leakage, can be life-saving and have a therapeutic effect.

2. The second indication is an abscess containing pus. Some surgeons believe that a well-formed cavity containing pus requires drainage. Many respondents attach importance to terms such as “undrained abscess” or “thick-walled abscess” as an indication for drainage. I'm surprised that such abscesses are actually found in the abdominal cavity!

3. The third general point is insufficient control over the source of infection. A variety of indications appear here, such as bile leakage, urination, the impossibility of forming a full-fledged external fistula of the duodenum or jejunum without an intermediate cavity, which is quite reasonable.

4. Difficult duodenal stump – danger of incompetence after gastric resection according to B-2.

5. Other situations such as the danger of urination, the danger of leakage of the esophageal suture line, which is also reasonable. Regarding the danger of possible bleeding, which, as a rule, is unnecessary and is rarely performed. Even with significant bleeding, this is just the tip of the iceberg.

Table 9. In what situation will you install drainage?

How to drain?

The authors' answers are very varied, especially taking into account the different manufacturing companies. Most indicate that drainage can be active (a round tube connected to a suction) or passive (a tube or flat drain operated by gravity). Table 10 shows that 60% of respondents prefer “active” drainage. North Americans prefer active drainage exclusively. Others use mixed drainage - tubular, wrinkled or Penrose drainage.

Which drainage is better? The different types of drains and their characteristics have been described in detail by O'Connor and Hugh []. It is desirable that the drainage be soft and elastic to minimize the real danger of compression necrosis of the intestine or its mesentery. Passive drainage works due to capillarity, gravity or pressure difference. Active drainage is connected to suction. Passive drainage is considered as an open system, which is associated with contomination of the wound drainage channel due to the retrograde spread of bacteria on the skin surface (“drainage drains in both directions”). Many authors believe that passive drainage is not effective in the upper abdominal cavity due to the negative intrathoracic pressure that occurs during breathing (1), others disagree (15).

Active drainage tends to become clogged with aspirated tissue or clots. High suction pressure blocks drainage. Double-lumen drainage is more resistant to blockage, but it usually consists of a rigid material and does not provide safety during prolonged standing in the abdominal cavity. Interestingly, a study of drainage after cholecystectomy showed that simple passive drainage was 2 times more effective than simple active suction drainage, and double-lumen drainage was more effective than passive one (15).

Flat and soft active are the only drains I use in the abdominal cavity, usually in rare cases of complex cholecystectomy. I will use these same drains in other situations, for example, when expecting a biliary or pancreatic fistula. Surgeons who use active drainage know that after a few hours it becomes clogged with fibrin and pus. And open passive drainage will act as a one-way highway (inward) for skin bacteria. As for surgeons who leave a drain near the colonic anastomosis, I would be surprised to learn that they rely on a tubular active drain to aspirate the feces. To remove it, a large passive tube (wrinkled drainage) with a significant (2 fingers) incision in the skin and abdominal wall is required. But in this case, complications such as a drainage hernia, acute intestinal obstruction, bleeding and abscess of the drainage canal are possible. For various drainage complications, see table. eleven.

Table 11. Complications of intra-abdominal drainage and their prevention.

These complications are real. Some are rare. But I have experienced each of them during the “dark period” of my career. Many can be prevented by careful handling of drains (Table 12), but the best way to prevent drainage complications is to avoid them when drainage is not indicated. The majority of residents indicate that they now drain the abdominal cavity less frequently than they previously did during the initial period of their surgical career (Table 13).

Table 12. Installation and management of drains

Introduction of drainage

• I choose the appropriate drainage according to the situation, but in general the softest and smallest in diameter.
• I install it strictly in the required area, trim the excess length, but leave it with some sagging.
• I place drainage away from the intestinal wall or vessels
• I try to place the omentum between the drainage and vital structures to avoid erosion
• I place the drain away from the main wound to prevent wound infection.
• I plan the shortest route for drainage placement, depending on the indications and type of drainage.
• When suturing the main wound, do not catch the drainage into the suture without fixing it to the fascia.
• Fix the drainage to the skin using a suture.

Control

• I use a closed system whenever possible
• I use low vacuum to prevent suction of nearby tissues to the drainage hole
• I take care of small-diameter tubes by rinsing them twice a day with a small amount of saline solution under sterile conditions.
• When a fistula has formed (eg, a biliary fistula), suction should be stopped and passive drainage by gravity should be used.

Removal

• I remove the drainage as soon as it stops working or performing its preventive function.
• Removal of long-standing drainage should be carried out in stages, “step by step” to prevent the formation of deep interstitial abscess
• Removal or shortening of the drainage can be carried out under ultrasound and CT control.
• If the drain is shortened, it must be reattached to the skin to prevent proximal migration.

Table 13. Do you drain more often now than at the beginning of your career?

Suction drainage from the pleural cavity

Suction tube

For suction drainage of the pleural cavity, various rubber and synthetic tubes are used.
For the most commonly used drainage, a rubber tube about 40 cm long with several side holes at the end is used. This tube is placed along the lung (from the base to the apex) and passed over the diaphragm from the pleural cavity to the outside. The drainage is attached to the skin with a knotted U-shaped suture. When the suction drain is removed, the threads are tied again, thereby sealing the hole in the chest. A three-barrel suction catheter (Viereck) is advantageous, allowing free passage of the tube inserted inside.

Insertion of suction drainage

In the chest between the two pleural layers, the intrapleural pressure is lower than atmospheric pressure. If air or liquid gets between the pleural layers, then the normal physiological state can only be restored by long-term suction drainage. A closed drainage system is used to suction pleural fluid for recurrent pneumothorax and to treat empyema. This drainage is now usually inserted into the intercostal space through a trocar. The thickness of the drainage tube is determined in accordance with the consistency of the substance being sucked out (air, as well as watery fluid or serous, fibrinous, bloody, purulent fluid).

On the drainage, mark with paint or thread the place to which it will be inserted. The size of the trocar must correspond to the size of the drainage. It is advisable to have at least three trocars of different sizes with suitable tubes of 5, 8 and 12 mm in diameter. Before inserting the trocar, you must make sure that the selected drainage tube passes through it easily.

The site of the skin incision is filtered with novocaine to the pleura. A test puncture in the designated area makes sure that the desired air or liquid is really there. The assistant gives the patient the necessary position: the patient must sit and lean on the highly raised operating table so that the puncture area protrudes as much as possible, and the selected intercostal space is, if possible, expanded. A scalpel is used to cut the skin over an area slightly larger than the size of the trocar. Then the trocar is inserted with a strong movement along the upper edge of the rib into the pleural cavity. After removal of the trocar, unimpeded release of fluid or free entry and exit of air indicates its correct insertion. Drainage is performed and the trocar tube is removed. If you are not convinced that the drainage is in the right place, you should, in order to prevent the trocar from puncturing the lung, heart or large vessel, perform the puncture again, taking all measures to localize it under X-ray control.

Before closing each thoracotomy hole, a drainage is introduced into the pleural cavity, which is brought out above the diaphragm through a separate hole in the intercostal space. Through a hole measuring about 1-2 cm, a forceps is inserted into the pleural cavity under the control of the eyes and under the protection of the left hand to ensure the correct position of the drainage from the inside. The drainage is pulled through the chest wall with a forceps from the inside to the outside. Pay attention to the fact that the drainage section, free from holes, is at least 5 cm in the chest cavity. If the fixation of the drainage to the skin is broken, then it slips out, and the first side hole appears outside the pleural cavity above the skin. In this case, the closed system turns into an open one, suction becomes ineffective, and pneumothorax often occurs.

Suction systems

There are so-called individual (“bed side”) and centralized suction systems. The suction action due to the hydrostatic effect can be obtained by a tube lowered under water, a water or gas pumping device (in this case the action is based on the valve effect) or an electric pump. Both individual and central systems must ensure individual regulation. If the release of air from the lung is insignificant, then due to its simplicity, the Biilau drainage system is still successfully used today, which can be sufficient to straighten the lung. A glass tube immersed under water (disinfectant solution) is equipped with a valve made from a finger cut off from a rubber glove, which protects against reverse suction. The Biilau system uses the physical law of communicating vessels to move bottles under the bed to create a suction effect.

The Fricar air pump best meets modern requirements. This device can work for many days without interruption and without heating up. The strength of the suction effect can be precisely adjusted.

Central suction devices are triggered by an oxygen canister system or a powerful suction pump. The system of outgoing tubes, if necessary, supplies hospital departments located on different floors. Depending on the need, the required number of hospital beds can be connected. An oxygen-powered system has the advantage that the suction and supply of oxygen to individual hospital beds is provided by the same tubing system. The suction effect is provided by a valve tube mounted along the oxygen flow. In this case, however, the effect produced by the central suction pump is not achieved.

Individual adjustment can be carried out using a dosimeter tap connected to a well-functioning pressure gauge, or through the so-called. three bottle system. The latter can be easily prepared by yourself. This system also has the advantage that it can easily and reliably create a very low suction effect (from 10 to 20 cm of water column). It is rarely possible to achieve such low pressure values ​​using factory pressure gauges.

Indications for suction drainage

Spontaneous and traumatic pneumothorax, hemothorax

Spontaneous pneumothorax occurs at a young age, more often as a result of rupture of single pulmonary alveoli in the apex of the lung, in older people - as a consequence of rupture of alveolar vesicles with diffuse emphysema. Due to the fact that the number of patients with emphysema is constantly increasing, the number of cases of spontaneous pneumothorax is becoming more frequent. The same applies to traffic accidents that result in closed injuries in the chest cavity, which often occur with pneumothorax or hemothorax.

Correctly performed pleural puncture for spontaneous pneumothorax is practically safe, and its benefits can hardly be disputed. If the flow of air from the damaged lung is completely stopped and the perforation site is closed, then it may be possible to completely remove the air that created the pneumothorax with a simple closed puncture. If pneumothorax recurs after puncture (even repeated), then drainage with long-term suction should be used. Recurrence of pneumothorax, even after prolonged drainage with suction, can only be reliably eliminated by surgery.

Traumatic pneumothorax most often results from rib fractures. When a rib fragment injures the lung, most often a significant amount of air comes out of it, and a tension pneumothorax occurs. At the same time, subcutaneous or even mediastinal emphysema may occur. Spontaneous pneumothorax can also occur when the pulmonary alveoli rupture or due to blunt force on an emphysematous lung. Therefore, in patients with pulmonary emphysema, chest injuries are often associated with the occurrence of pneumothorax, often severe tension pneumothorax. The principles of treatment for spontaneous and traumatic pneumothorax are the same.

If clinical symptoms indicate tension pneumothorax (severe respiratory failure, subcutaneous emphysema, mediastinal shift), then drainage of the pleural cavity should be performed immediately. If these symptoms are not present, then a closed puncture is performed and the air is sucked out. After this, the needle is left inserted into the pleural cavity, and its nozzle is connected to a pressure gauge and the pressure in the pleural cavity is determined (whether it is higher or lower than atmospheric). If the pressure in the pleural cavity is indicated by the pressure gauge needle in the positive direction, it means that air continues to be released into the pleural cavity, and, therefore, drainage is necessary. This issue can, of course, be resolved by X-ray examination. If there is a total pneumothorax, then drains are inserted in two different places. One of them runs along the posterior axillary line above the diaphragm in the VII-VIII intercostal space, the other is inserted along the midclavicular line between the 1st and 2nd ribs. In our experience, drainage inserted under the collarbone performs the task of straightening the apex of the lung better.

In case of encapsulated limited pneumothorax, drainage should be inserted locally, under X-ray control after a test puncture.

Empyema of the pleura

Pleural empyema is a disease for which treatment with suction from the pleural cavity is absolutely indicated.
The principle of treatment of empyema does not depend on the causative agent of the disease. It consists of gluing the pleural layers and eliminating the empyema cavity through early drainage and suction of fluid. Treatment with suction from the pleural cavity is combined with targeted local chemotherapy, based on the identification of the pathogen and its resistance to the drugs used. Most empyemas result from infection of the exudate. In this case, incorrect and insufficient suction from the pleural cavity plays a certain role. In cases where pockets with delimited fluid form in the pleural cavity, their complete emptying becomes increasingly difficult, more difficult, and infection is more likely. In such cases, complete recovery can only be ensured by surgery.

Suction treatment may fail for two reasons: one is the presence of pleural cords, the other is a bronchopleural fistula.

Pleural moorings are often the result of insufficient emptying of the pleural cavity. When moorings have already formed in the pleural cavity and the walls of the empyema cavity are thickened, there is little chance of eliminating the empyema by suctioning out the fluid. The ability to expand the lung in this case is also very controversial. In this case, drainage with suction is a preparatory measure before the inevitable operation. Radical surgery (decortication) is performed only after the patient’s general condition has improved by washing the pleural cavity and targeted antibiotic therapy.

Bronchopleural fistula reduces the effectiveness of suction and thereby the prospect of lung expansion. In cases where there is a large bronchial fistula and its closure is contraindicated (for example, a rupture of the cavity, tumor disintegration, rupture of a cystic, emphysematous lung that has lost its elasticity), success cannot be expected from the use of suction. On the other hand, suction can also be used in cases where surgery is indicated. In elderly patients, with low general resistance and the possibility of severe complications, surgery becomes impossible. Then all that remains is to leave the patient with permanent drainage.

In case of chronic pleural empyema, drainage should be inserted into the pleural cavity at its lowest point. Large-diameter drains are used so that the thick liquid does not close the lumen and it is easy to wash the pleural cavity. Often, in the area where the drainage will be introduced, a rib resection (2-3 cm) is performed.

Postoperative suction from the pleural cavity

In order to remove fluid that accumulates after thoracotomy from the pleural cavity and maintain normal intrapleural pressure, a suction drain should be available.

If during pleural operations and mediastinal, transthoracic interventions on the esophagus, stomach, heart and large vessels there was no damage to the lung, then the chest can be closed with the introduction of one perforated drainage into the pleural cavity. Drainage is carried out above the diaphragm along the midaxillary line with its pleural end installed at the level of the apex of the lung.

Two drains are inserted into the pleural cavity if the lung was damaged during separation of adhesions, as well as after resection or excision of lung tissue. In such cases, one of the drains is inserted along the anterior and the second along the posterior axillary line. The use of a third drainage may be considered relatively appropriate when it is brought to the site of anastomosis of the esophagus or bronchus or when thoracoplasty is performed in combination with lung resection (for suction from the subscapular space).

After removing the lung, one drain with a diameter of 12-15 mm is inserted into the pleural cavity and placed in the lower part of the cavity so that a piece of drainage 10-12 cm long is equipped with 2-3 side holes. Active suction through this drain is prohibited.

After median sternotomy, a drainage is inserted retrosternally and its second end is brought out in the epigastrium.

Intensity and duration of suction

The intensity of suction through drainage from the pleural cavity depends on the cause of the disease, the condition of the lung and the nature of the operation. The flow of air from the lung into the pleural cavity is of decisive importance. If this occurs, then more air should be sucked out of the pleural cavity per unit time than is supplied there. Only in this way can gluing of the pleural layers be achieved. In practice, however, this is often not feasible. If the connection of the bronchus with the pleural cavity is significant (for example, in the case of a bronchial fistula), then intensive suction cannot achieve the goal. If you increase the suction force, then at the same time the patient will experience increased respiratory failure due to “air theft” from the tidal volume. Despite this, the lung will not be able to expand. In such cases, surgery is inevitable.

When the lung is damaged or after lung surgery, air most often escapes from a hole the size of a pinprick. In this case, specialized suction is indicated. In children and adolescents, due to the fact that their lung parenchyma is healthy and not affected by fibrosis and emphysema, it does not matter with what force the suction is performed. It doesn’t matter whether they suction with an intensity of 25 cm of water. Art. or simple underwater drainage, the lung will expand in 24-48 hours. The drainage can be removed after 48-72 hours. This is the advantage of elastic tissue capable of lung retraction in young patients. With emphysematous lung in an elderly person, the situation is different. The pinprick holes become gaping holes in the lung because the surrounding tissue is unable to contract. If you try to reduce the flow of air coming from the damaged lung by increasing the intensity of suction, you can easily get a paradoxical effect. The flow of air from the lung will increase. Small holes, due to prolonged suction, stabilize and turn into fistulas.

What to do in such cases? Begin gentle suction from the pleural cavity (5-6 cm of water column) and pay attention to ensure that tension pneumothorax does not occur. Thanks to this, the resulting fibrin seals small holes in the lung. Within 24 hours, a decrease in the release of air from the damaged lung begins to be detected. The intensity of suction can be increased slightly. On the fourth day you can already suction with an intensity of 10 cm of water. Art., if no unforeseen complications arise, then the drainage can be removed on day 4-5.

The same principles are followed when treating spontaneous and traumatic pneumothorax with suction.

If there is a significant intake of air from the emphysematous lung, they begin to carefully perform suction with a gradual increase in its intensity. If, after many days of treatment with suction, the release of air from the lung does not stop, then it is recommended to immediately undertake surgery, without waiting for the development of infection in the pleural cavity. If suction from the pleural cavity continues for more than a week, the development of infection becomes real.

In cases where the patient does not undergo surgery due to low general resistance, suction from the pleural cavity remains to be continued. Prolonged and specialized suction under the guise of drug treatment may be more or less effective. The pleural layers are glued together completely or partially. Only small limited cavities remain that do not lead to complications. The drain can be removed.

In the treatment of pleural empyema, long-term use of suction drainage is a common method. The empyema cavity gradually becomes smaller and smaller, the amount of fluid decreases, and in the end it can become bacteriologically sterile. If the daily amount of fluid extracted from the pleural cavity does not exceed 10-15 ml, then the suction is stopped, the drainage is shortened, but left until the residual cavity is completely closed.

Geographical differences in practice

Surgeons in North America tend to limit the use of drains for most indications, while surgeons in Asia and Eastern Europe are enthusiastic about drains. This primarily applies to diffuse peritonitis and emergency colon surgery. Today we have the right to ask why surgeons in North America, as well as Western Europe and Latin America, place less drainage? This is influenced by several factors:

• With the improvement of surgical techniques, the effectiveness of antibiotics, and the improvement of image quality at the diagnostic stage and after surgery, the results of emergency operations have improved. Surgeons began to encounter fewer and fewer complications that drainage could prevent. Why drain if it is not necessary?
• The availability of CT scans has also given surgeons more confidence. The mysterious postoperative abdominal cavity is no longer a “black box.” There is no longer a need to rely on drainage to alert you to the development of an abscess.
• The great success of image-guided percutaneous drainage of intra-abdominal collections and abscesses has added confidence to surgeons that there is no need for thick tubes for many days to clear an abscess.
• Modern surgeons understand that there is no need for drains to “prevent and treat” persistent or recurrent infection after, say, perforated appendicitis. They teach that most patients will be fine after removal of the source (appendectomy) and antibiotic therapy. And if not, CT and percutaneous drainage under CT guidance will help them.

There remains the question of the continuing enthusiasm for drainage in Asia and Eastern Europe. Perhaps the lack of availability of CT in developing countries forces surgeons to continue to rely on drains. Or they are more subject to local dogmas, reinforced by strict discipline. The latter seems very likely. In my practice, we stopped routine use of drains in the mid-1980s, long before the advent of CT scanning and percutaneous drainage. However, we already understood what surgeons know today: with or without CT, many drains are unnecessary and counterproductive. We are reminded of the words of William Stewart Halsted: “Not having drainage is better than installing it illiterately.”

Kinds

Drainage can be passive, flow-flushing or active.

Types of drainage (source https://studfiles.net/preview/4603856/page:16/)

Passive

Passive drainage is currently carried out using perforated tubular systems made of polyvinyl chloride or thin tubes filled with gauze. Drains are positioned in such a way that they drain the liquid component from top to bottom. This mechanism of action is ensured by the force of gravity pressing on them.

Active

When performing active drainage of sealed tissue and epidermal damage, aspiration is used based on vacuum, provided by a special suction. This technique allows you to remove dead flesh, minimize the joining of wound edges, and reduce the likelihood of pathogenic microflora entering the cavity from the outside.

The drainage is installed in such a way that it removes the separated liquid from the bottom up, against the influence of gravity on it. It is necessary to take into account that this drainage is not used to remove growing hematomas.

Flow-flushing

Flow-flush type drainage is carried out using aspiration flushing with the installation of counter-perforated drainage systems. Medicine is injected into one of them, and transudate is removed from the damaged tissue through the second.

The drug can be administered into the drainage in a stream, drip, fractionally or continuously. Outflow is carried out according to the active or passive method. With the help of such drainage, pathogenic microorganisms do not enter the wound, transudate is completely removed from it, thus creating favorable conditions for healing and unfavorable conditions for bacteria.

Postoperative wounds are drained due to the high risk of developing inflammatory processes of purulent etiology. This situation is due to the fact that contamination occurs in the wound during surgery, represented by subcutaneous tissue and the impossibility of completely removing dead tissue.

Drainage must be installed by introducing counter-perforated systems into the cavity through the holes left from dialysis after surgery. Drainage is often prescribed in the case of removal of cancerous formations in the mammary gland, local hernias of the ventral type, amputation of the lower and upper extremities and surgical cleansing of a purulent focus in soft tissues.

After the purulent focus is opened, the doctor installs passive drainage, which is always done in such cases. The technique of installing drains is studied by operating nurses in the dressing room or operating room when working with patients with various types of wounds.