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42 Abdominal Drainage 459
Drainage After Omentopexy for Perforated Ulcer (> Chap. 18)
The literature dealing specifically with drainage after omentopexy for perforated ulcer is scanty but does not support drainage. Omental patch repair, if correctly
performed and tested (> Chap. 18), should be leakproof. In addition, the presence of
drains when a leak occurs is usually not a lifesaver.1 Fu ti le r eli an ce o n the drain w hen
a leak develops simply postpones lifesaving reoperation and hastens death.
What about laparoscopic omental patch repair—an increasingly popular
procedure: should it change the (non)indication for drainage? With leaks after
omentopexy being so rare and large series comparing open to laparoscopic repair
so scanty, it is difficult to appreciate whether leaks are more common after laparoscopic repairs. However, those of us used to open omentopexy should be
alarmed to see the reported leakage following laparoscopic repairs. It may be that
the “learning curves,” the inability to feel the tension placed on the sutures to tie
down the patch, or the reliance on suture closure rather than using the omentum
make the laparoscopic approach more prone to leakage. But, would the drain
help to avoid the ensuing disaster? We doubt it (> Chap. 18). So, if you know how
to do a proper and safe omental repair, draining it would be superfluous. If you
are learning to do a laparoscopic repair (with the declining incidence of peptic
ulceration, you may never reach the top of the learning curve), you may want to
leave a drain. It will not avoid the need for reoperation should leakage develop,
but it may warn you early that this is the case. On the other hand, a well-timed
contrast study (with or without computed tomography [CT]) would provide you
with more information than the often poorly placed and nonproductive drain.
Question: Would you place a drain following a Hartmann procedure for
perforated sigmoid diverticulitis or cancer? Would you place a drain following a
colectomy and primary anastomosis for perforated sigmoid diverticulitis or cancer (> Chap. 26)?
Answer: These two questions, about drainage after emergency resection of
perforated sigmoid colon without or with primary anastomosis can be discussed
together. In both situations, source control has been achieved by the colectomy;
thus, the rationale for drainage would be “therapeutic” (to help treat the associated intraperitoneal infection) or “prophylactic” (to prevent collections or to
“control” potential leakage from a suture line, e.g., rectal stump closure). About
two-thirds of responders to both questions would not drain routinely.
1
A “side” leak from the duodenum is a very serious complication, almost impossible to control with
simple drainage alone; instead, to improve chances of survival a reoperation is required to stop the
leak (e.g., Billroth II gastrectomy) or at least convert the “side” duodenal fistula to the more managea b l e “ e n d ” d u o d e n a l fi s t u l a ( e . g . , g a s t r o j e j u n o s t o m y p l u s t u b e d u o d e n o s t o m y o r “ d u o d e n a l e x c l u s i o n ” —
closure of the pylorus and gastrojejunostomy).
460 Moshe Schein · Paul N. Rogers
Drainage After Emergency Left Colon Resection
With or Without Anastomosis (
The topic of drainage after colonic resection has been subjected to intensive
debate for the last 30 years; proponents claim that drains would avoid reoperation
if anastomotic leaks develop, while critics contend that drains actually contribute
to leaks. It would be difficult to improve on the review and meta-analysis by
Petrowsky et al. (2004), which denied any benefits to drainage. Even the usually
overly cautious Cochrane Review concluded that “there is insufficient evidence
showing that routine drainage after colorectal anastomoses prevents anastomotic
and other complications.”
The reasons given by those in favor of drains are varied:
The first is to help combat residual, or prevent recurrent, intra-abdominal
infection by draining the pericolic abscess found and already drained during operation or by removing secretions. The futility of peritoneal drainage in achieving such goals has been discussed in this chapter (see acute appendicitis) and
needs to be re-emphasized (see next question).
The second is to drain the anastomosis should it leak. But, surely high-risk, leak-
prone anastomoses should not be constructed in the emergency situation anyway;
furthermore, as the literature points out, drains do not help much if leakage does
develop—to say nothing about the false sense of security they tend to provide.
The third reason given is to provide drainage to the rectal closure (Hartmann’s
pouch) should it leak. But, a solid stapler-or hand-closure of the healthy rectum
away from the colonic inflammation should provide a leakproof closure. When,
however, the closure is deemed “too difficult,” then the rectal stump should be left
partially open (around a tube) as advocated by the late John Goligher of Leeds. In
any event, only a pathological optimist could hope that feces will climb up the drain
and out of the pelvis, that is, if the drain is not already clogged by fibrin, clots, or
feces. In conclusion: drains after emergency colonic resection are a waste of time!
>
Chap. 26)
Question. Would you drain the peritoneum in generalized peritonitis
(> Chap. 12)?
Answer: Only about a third of responders would drain the peritoneal cavity
in generalized peritonitis.
Drainage in Generalized Peritonitis (
No comparative studies of drainage versus nondrainage in patients with diffuse peritonitis have ever been conducted because the futility of drainage in this
situation was perceived long ago by experts in surgical infections. The modern
view, endorsed by the Surgical Infection Society, maintains that:
Chap. 12)
42 Abdominal Drainage 461
“It is impossible to drain the peritoneal cavity in patients with diffuse peritonitis. Therefore, the use of drains in these patients is not indicated unless: (a)
the drain is to be used for postoperative lavage; (b) the drain is placed into a well
defined abscess cavity, (c) the drain is used to establish a controlled fistula.”
We recall, when we were junior residents, postoperative patients with multiple
rubber drains sticking out of each and every quadrant of their distended bellies.
Those drains produced some old blood or perhaps a little pus or foul-smelling fluid.
Then, the patient would die with the death blamed on “pneumonia.” How stupid we
we re — be li ev i ng th at th es e d r ai ns we re us ef ul . We g ra du al l y u nd er st oo d h ow wo r th less they were: all intraperitoneal drains seal off by adjacent tissue within 24–48 hrs
unless “perfused” by liquid effluent such as bile. So, in peritonitis, if you use a suction drain it drains almost nothing, and if you leave a wicking rubber drain (e.g.,
Penrose, “corrugated”), the drain simply drains the infected tract it has created.
The only indication to use a drain in general peritonitis is to control an
uncontrollable source of infection such as a leaking duodenal suture line or a
leaking gastroesophegal anastomosis. As pointed out, we are skeptical about the
terms well-defined or formed abscess as an indication for peritoneal drainage.
Such “abscesses” are pus collections that are part of the spectrum of peritonitis;
after evacuation, they should be treated like the rest of the infected peritoneum.
Let peritoneal defenses and antibiotics do the job. In conclusion, drains in diffuse peritonitis are senseless. Recurrent or persistent intra-abdominal infection,
however, often develop and may need percutaneous drainage (> Chap. 49), or a
reoperation (> Chap. 52). Drains will not change this.
Question: In which situations would you always drain?
Answer: Not many data are available to support any “scientific” opinion,
but here are the situations considered by experienced surgeons as “obligatory for
drainage”:
High probability of leakage of bile or pancreatic juice. This was the number
one indication and rightly so. Bile and pancreatic juice are well collected and
evacuated by drains. A drain placed for biliary or pancreatic leak may be lifesaving and curative.
Established pus-containing abscess. This was the number two indication,
showing that many surgeons believe that a well-formed collection of pus deserves
a drain. Many responders emphasized the term noncollapsible abscess or thick-
walled abscess as an indication for drains, but we wonder, does one really find
such an animal within the abdomen?
Not satisfied with “source control.” This was the number three indication;
it overlaps with other indications such as bile leak, urinary leak, or the impossibility of exteriorizing a leaking proximal jejunum or duodenum.
462 Moshe Schein · Paul N. Rogers
Difficult duodenal suture line. The “difficult” or leak-prone duodenal stump af-
ter Billroth II gastrectomy is another reasonable indication for prophylactic drainage.
The retroperitoneal duodenum is more susceptible to leakage; thus, draining it would
make sense (e.g., after duodenotomy to control hemorrhage following endoscopic
retrograde cholangiopancreatography [ERCP] and sphincterotomy. > Chap. 30).
Other indications. Prophylactic drainage when leakage of urine is likely is
another good indication, as is drainage of esophageal suture lines (> Chap. 15).
About drainage for expected bleeding, it has been said: “If you have to u se drains to
take care of postoperative hemorrhage, then you did not finish the operation.” In
most cases for which you leave drains for bleeding or oozing, they are unnecessary
and produce little; they also produce little when severe bleeding develops—showing
only the tip of the iceberg.
Question: Which type of drain do you use?
Answer: The responders came up with a potpourri of drains. Sixty percent
preferred “active” drains. While North American surgeons use predominantly
“active” suction drainage (e.g., Jackson Pratt [JP] drain); many other prefer “passive” drains, whether round (hollow) or flat (e.g., Penrose or the corrugated rubber). But, which drains are best?
The “Optimal” Drain
Preferably, all drains should be soft and malleable to minimize the real dan-
gers of pressure necrosis and erosion of bowel and blood vessels. Passive drains
work by capillary action, gravity, or overflow caused by slight pressure differences.
Active drains are connected to a source of suction. Passive drains are considered to
be an “open system,” proven to be associated with contamination of the drain tract
by retrograde spread of skin bacteria (“Drains drain both ways.”). Theoretically, applying a sterile colostomy bag over a drain site should convert the open system to a
closed one, but we doubt that this remains “closed” for more than a day. Whether, as
some claim, passive drains are relatively inefficient in the upper abdomen because
of the negative inward sucking pressures generated during respiration is controversial. Active drains tend to be clogged by tissue or clots, which are “sucked in”—the
higher the sucking pressure, the more prone to blockage the drain is. “Sump” suction
drains (double-lumen system) are more resistant to blockage but usually are of rigid
construction and thus not considered safe for a prolonged stay in the peritoneal
cavity. Evidently, the larger the drain, the wider the exit opening in the skin—the
more effective is the drainage but also the more it is prone to complications.
But, practically:
T h e fl a t a n d s o f t a c t i v e J P i s t h e o n l y i n t r a p e r i t o n e a l d r a i n t h a t w e u s e t h e s e d a y s
in “routine” practice, usually for the occasional case of difficult cholecystectomy.
42 Abdominal Drainage 463
Table 42.1. Complications of intraperitoneal drains
Complication Complication
Drain “fever” Failure to retrieve (caught by fascial sutures, torn,
Drain tract infection
Drain tract hernia
Drain tract bleeding
Intestinal obstruction
Erosion of bowel
Erosion of vessels
or knotted)
“Lost” drain: migration into the abdomen or breakage
Contamination of sterile tissues
Prevention of healing of fistulas
This is the drain we would use for indications such as a potential duodenal or
pancreatic fistula.
If you are one of those who drain peritonitis, remember that your suction
drain will be plugged with fibrin and pus within a few hours, and your open passive drain would serve mostly as a one-way autobahn for skin bacteria.
For those who place drains adjacent to colonic anastomoses, do you really
believe that suction drains will evacuate feces? To form a channel capable of
transferring fecal material to the outside, one has to use a large passive (e.g., corrugated) drain through a generous, two-finger, opening in the skin and abdominal wall. But by doing so, we would go back to the old days of drain site hernias,
intestinal obstruction, bleeding, and drain site abscess formation.
For a list of complications of drains, look at > Table 42.1. These complica-
tions are real; some are rare, but we have experienced each of them in the dark
ages of excessive drainage. Such complications can be prevented by correct placement and management of drains (see > Table 42.2) or, better, avoiding drains
when not indicated.
Regional Differences in Practice
From the international feedback we received, this trend is obvious: North
American surgeons tend to be abandoning drainage for most indications, while surgeons in Asia and eastern Europe still seem to be enthusiastic about drainage. Such
differences are particularly notable concerning drain placement in diffuse intraabdominal infections and emergency colonic surgery. But, why do North American,
464 Moshe Schein · Paul N. Rogers
Table 42.2. The placement and management of drains
Insertion
Choose a suitable drain for the specific job but in general go with the softest and
smallest
Place drain carefully in the desired region, trim it to remove excessive length but
leave some “slack”
Place it away from bowel wall or vessels
Try to bring omentum between the drain and vital structures to prevent erosion
Bring drain out through the skin, away from the main wound, to prevent wound
infection
Plan the shortest tract possible and, depending on the indication for drainage and
type of drain, try to exit it in a dependent location
When closing the main wound, be careful not to catch the adjacent drain with your
fascial sutures
Secure drain to skin with suture and tape
Management
Use a “closed” system whenever possible
Use a low suction to prevent sucking adjacent tissue into drain’s holes
To keep small-caliber tube drains patent, they can be flushed twice daily with
small amounts of saline under sterile conditions
When a fistula is established (e.g., biliary), suction can be disconnected and drain
connected to a dependent bag, draining on gravity
Be careful that the drain’s tip is not abutting the visceral defect it is draining—this
would prevent the closure of the defect: check for drain position with a sinogram
Removal
Remove as soon as drain not productive or seems to have performed its prophylactic
task
Long-term drains should be removed in stages to prevent abscess formation in the deep
tract
Removal and shortening of drains could be guided (selectively) with sinograms or
CTs
When shortening the drain, refix it to the skin to prevent proximal migration
western European, and South American surgeons tend to rely less on drains? Such a
shift in habits has surely occurred gradually and is due to multiple factors:
With improved surgical techniques and antibiotic administration and better
imaging, results of emergency abdominal procedures were improving. Thus, surgeons were noticing fewer complications that could have been allegedly prevented
42 Abdominal Drainage 465
by drains. This provided surgeons with a new sense of confidence: why should they
leave drains if the drains seem mostly unnecessary?
Readily available CT scanning added to the surgeons’ confidence. Now, the
mysterious postoperative abdominal cavity is no longer a black box. We do not
need a drain to warn us that there is an abscess; we can see it on the CT.
The immense success of image-guided percutaneous drainage of intra-ab-
dominal collections and abscesses has obviously added to that confidence. And, it
also taught us much about the methodology of drainage itself—that you do not
need huge tubes, for many days, to get rid of an abscess. The elaborate rituals surrounding management of drains were evaporating as well.
So, modern surgeons found out that they do not need drains to “prevent or
treat” persistent or recurrent infection after, say, perforated appendicitis. They
learned that most patients would do well with source control (appendectomy)
and antibiotics. And, if not, they would CT scan the patients and if necessary
drain whatever was there under CT guidance.
What Is Behind the Persisting Enthusiasm for Drains
in Asia and Eastern Europe?
Is the persisting enthusiasm for drains in Asia and eastern Europe because
the relative unavailability of postoperative CT in the “developing countries”
makes the surgeons unable to gather the confidence to omit drains? Or, are the
surgeons more forcefully subjected to local dogmas, entrenched by strict discipline? It seems so. It was during the mid-1980s that we abandoned routine drainage for the conditions discussed. At that time, we did not have CT and percutaneous
drainage to bail us out, but we understood then what surgeons should understand today—that with CT or without CT, most drains are unnecessary and
counterproductive.
Let us then repeat William Stewart Halsted’s motto: “No drainage is better
than the ignorant employment of it.”
Conclusions
The use of routine drainage in contaminated and infected abdominal surgery is declining but still practiced in some regions of the world. Drains should be
used very selectively, when their placement is the only way to control the source of
infection; to provide escape for highly predicted leaking fluids (bile, pancreatic
juice, urine); to drain a noncollapsible abscess (a rare animal); or to drain, for
466 Moshe Schein · Paul N. Rogers
Fig. 42.1. Confused resident: “Boss, he’s still sick.” Old-fashioned surgeon:
“Perhaps we should have placed more drains.”
short duration, a very oozy surface (we are not sure about this last “indication”!).
Prophylactic drainage of the general peritoneal cavity is senseless (> Fi g. 42.1),
while drainage of an intestinal anastomosis may be dangerous.
“Although more than five million surgical drains are used each year in the United
States, their effectiveness, therapeutic indications, and efficiency remains an unsolved
controversy.” (J.P. Moss)
Reference
Petrowsky H, Demartines N, Rousson V, Clavien PA. (2004). Evidence-based value of pro-
phylactic drainage in gastrointestinal surgery: a systematic review and meta-analysis.
Ann Surg 204:1074–1085.
Abdominal Closure
Moshe Schein
Big bites, with a continuous monofilament suture and—above all—avoiding
tension. This is how to avoid dehiscence and herniation.
Finally, it is time to “get the hell out of here.” You have been working all night,
and it is tempting to finish hastily. Impatience, however, is inadvisable since correct abdominal closure protects the patient from abdominal wound dehiscence
(and later on from the development of a hernia) and you from great humiliation
(“everybody knows”). Yes, you are tired, but before closing, stop and think; ask
your assistants: “Did we forget to do anything?” See the checklist in > Chap. 44.
Generally, an abdominal closure fails because of poor quality of the tissues,
increased intra-abdominal pressure, faulty technique, or a combination of all of
these. Very rarely, a suture knot comes undone or a damaged suture breaks, but
more typically, the fault lies with the tissue and not the suture. To achieve secure
closure, keep in mind (and hands) the following discussion.
43
Principles of Closure
Suture Material
Use a nonabsorbable (e.g., nylon or Prolene) or “delayed” absorbable (e.g.,
PDS or Maxon) monofilament suture. Rapidly absorbed materials such as vicryl
and Dexon are still widely used even though their use is illogical in view of wound
repair kinetics. Those who fancy such suture material produce the hernias for the
rest of us to repair. Nonabsorbed or slowly absorbable suture material, on the
other hand, keeps the edges of wound together until its tensile strength takes over.
Monofilament sutures are advantageous because they slide better, inflicting less
“saw injury” to the tissues and, when used in the preferred continuous fashion,
distribute the tension evenly along the length of the wound. The use of braided
nonabsorbable material (e.g., silk) is associated with chronic infected sinus
formation and belongs, we hope, to remote history. Monofilament material is not
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_43, © Springer-Verlag Berlin Heidelberg 2010
467
468 Moshe Schein
prone to breakage, but damage to the suture during insertion can make this more
likely. It is therefore important to avoid grasping the suture material itself with
forceps because this can damage its integrity and weaken it.
“Mass Closure”
“Mass closure” is the preferred technique, as documented in numerous studies. It has been popularized for the closure of midline incisions but is as effective
for the closure of transverse muscle-cutting incisions. For the latter, however,
many surgeons still prefer layered (posterior fascia–anterior fascia) closure. We
also do. For example, to close a subcostal incision, we would run a looped PDS 1
from the center laterally, taking the posterior sheath; at the lateral corner, we would
lock the suture and run it back medially, taking the anterior sheath, and tying the
knot at the medial corner of the incision.
Mass closure entails monolayered suturing of all structures of the abdominal wall in a continuous manner to provide “one strong scar.” The secret here
is to take large bites of tissue, at least 1 cm away from the wound’s edges; the
bites should be closely spaced so not to create gaps greater than 1 cm. Avoid the
common mistake of carefully excluding muscle in your fascial bites; this may
look cosmetically appealing as the muscle is hidden away under the fascia but
does not produce the desired “mass scar.” No less important is the issue of the
correct tension to be set on the suture (> Fig. 43.1). If you pull the suture too
tight, the tissue is strangulated and necrosed; if you keep the suture too loose,
the wound edges gape. Bear in mind that the muscles are relaxed as you close
Fig. 43.1. “Jack, what are you doing?”… “The boss told me to close it tight”…
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