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10 Fundamentals ofStapling Devices
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139
that inordinate force is not placed on the newly
created staple line.
In laparoscopic cases, the staplers can be
manipulated in multiple directions by articulation. Articulating the stapler prior to placing it in
contact with tissues is ideal to avoid grasping the
tissue with the stapler as it is adjusted. The laparoscopic staplers have a narrow end which acts as
the anvil; this narrow end should be inserted
through any window in the tissue (e.g., between
an appendix and mesoappendix), and the larger
side should be applied externally to avoid forcing
the larger side of the stapler through a small
opening.
10.3 Current Devices
Surgical staplers used today are largely disposable and have become much easier to operate.
Most of the devices have both an open and a laparoscopic counterpart. Linear staplers are available with multiple types of handles and cartridge
congurations, allowing for tension-free
application in various settings. The linear staplers
include both models which apply staple lines and
divide the tissue between the staple lines during
the ring (GIA staplers) and also models which
apply a staple line without any severing of tissue
(TA staplers) [8]. These staplers require the operator to divide the tissue sharply after ring the
stapler. Both of these linear staplers are available
in endomechanical versions as well for use in
laparoscopy and thoracoscopy. A modication of
the linear stapler is a curved staple load red in
the same way with a blade between the staple
lines, allowing for control and division of tissues
in difcult to reach areas, such as the rectum. The
curve allows the stapler to be applied to a structure deep in the pelvis or in another narrow area
without placing torque on the stapler and thus
decreasing the risk for shear of the tissues [7].
Circular staplers have been developed mainly
for the creation of end-to-end anastomoses. The
circular staplers allow ring of staple lines circumferentially and also excise a ring of tissue
allowing connection of the two lumens. Circular
staplers are generally used near an end of the GI
tract as the stapler itself must be inserted through
the tubular viscera and aligned with a prepositioned anvil in the other end of the planned anastomosis but can also be inserted via an
enterotomy. The introduction of circular staplers
allowed for stapled anastomoses in areas where
tissues are difcult to mobilize, making distal
rectal stapled anastomoses possible and much
more facile [7].
10.4 Applications ofSurgical
Staplers
The widespread use of surgical staplers over the
last half century has led to adaptation of the technology for use in multiple organ systems and
various modes of operation. The original staplers
were created for use in gastrointestinal surgery,
and much of the data regarding technical aspects
of staple size choice and outcomes have been
derived from the eld of bariatric surgery [7, 10,
11]. Staplers are used frequently in bariatric sur-
gery: linear staplers for division of the stomach in
sleeve gastrectomy and jejunojejunal anastomoses in gastric bypass and circular staplers for gastrojejunal anastomoses in gastric bypass. Shorter
staple heights are associated with lower postoperative bleeding rates when circular staplers are
used for the gastrojejunal anastomosis [10, 11].
Special attention must be paid to the size of the
staples used on the stomach due to the varying
thickness of the stomach in different anatomic
regions in contrast to the colon which tends to be
more uniform in thickness. Longer staples are
generally used in the distal stomach as the distal
stomach tends to be thicker [7]. Long staple lines,
although sometimes necessary, can cause additional complications, especially leaks [12, 13]. In
addition, a higher number of intersections of staple lines are associated with a higher risk of leak
[13]. This situation typically occurs when creating a stapled anastomosis between two segments
of bowel which already have stapled ends. This
increased risk can be mitigated by inverting one
staple line into another [13].
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C. Souther and K. Murayama
Throughout the gastrointestinal tract, linear
staplers can be used to divide the small bowel or
colon without spillage of contents, and curved
staplers with long handles can be used to reach
deep into the pelvis to divide the distal sigmoid
colon or rectum without placing tension on the
colon or torque on the device. Circular staplers
are used frequently for distal sigmoid or rectal
anastomoses. Ideally a single staple load is used
to divide bowel as the use of multiple linear staplers for the same anastomosis can result in
higher rate of anastomotic leak [7], making the
curved stapler that can traverse the rectum in one
application safer.
Esophagectomies and the subsequent anastomoses can be performed using both linear and
circular staplers. Emergent situations such as
bleeding esophageal varices can be managed
with stapling devices as well by obtaining hemostasis using staplers to divide the esophagus and
control the bleeding, followed by reanastomosis
using additional staplers after the enlarged veins
have been controlled [14].
Division of the pancreas can be simplied
with the use of a stapler, and this method is commonly used for sealing the remaining portion of
the pancreas after distal pancreatectomy [15].
Appropriate choice of staple height [15] and adequate compression duration [7, 16] are important
for the prevention of pancreatic stula in these
cases. The thickness of the pancreas has been
found to independently predict formation of a
pancreatic stula after stapled distal pancreatectomy making the decision to use the stapler and
the choice of cartridge signicant [17].
Linear staplers can be used in open and laparoscopic hepatic resections both for the division
of the liver parenchyma itself and also for vascular control for the segment undergoing removal
[18, 19]. As in other organ systems, the thickness
of the liver can affect the success of staple line. In
vitro studies have suggested that the liver measuring more than 10 mm in thickness can have
other important factors inuencing risk of staple
line failure including stiffness which does not
seem to play a role in the liver which is not as
thick [18]. Staplers have also been used to divide
enlarged cystic ducts in biliary operations during
which a clip cannot t entirely across the duct
[20].
Pulmonary surgery has beneted from the use
of staplers in lung resections [5, 7]. However, the
air distribution in the lungs can make the thickness of the tissue more variable than in other
organs. Since additional air is located in the
periphery of the lung, the compression time and
pressure required during application of the stapler are lower than those required in more central
portions of the lung which contain bronchial tissue and more blood to displace prior to ring the
stapler [7]. Baseline pulmonary health must be
considered when stapling lung parenchyma as
the thickness can be affected by malignancies,
brosis, and chemical damage, while bronchopleural stulae are more likely in emphysematous lung parenchyma [7]. Overall, the stapling
of lungs leads to better aerostasis than hand-sewn
pulmonary resections [7]. Methods including
folding over the edges of bronchi prior to anastomosis to decrease tension placed at the center of
the staple line have been employed to improve
the success rate of pulmonary stapling [21].
10.5 Current Controversies
Given that leaks or bleeding are dreaded complications of endomechanical devices, the staple
lines can be reinforced by the use of several “buttressing” materials which can be absorbable or
permanent. Many surgeons advocate for their
use, but the need for reinforcement, as well as the
method providing the most benet, is widely
debated. Some authors report no benet in reinforcing staple lines [22]. In several studies,
decreased leak rates and lower rates of bleeding
have been seen after oversewing the staple line
[23–26]. Some advocate using bovine tissue buttresses rather than simply suture reinforcements
to the staple line [23–25]. There is some concern
for stenosis which can occur when additional
sutures are placed, so care should be taken when
reinforcing staple lines to avoid decreasing the
patency of the anastomosis [26].
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141
10.6 Summary
The rst surgical stapler designed by Hultl initially designed to control spillage of bowel contents and improve asepsis paved the way for the
modern devices which make many operations
easier to accomplish and increase their efciency.
Many organs can be divided and anastomosed
using stapling devices, and a variety of modications have been made to suit tissues of different
character and size. Surgeons must pay close
attention to mechanical aspects of staple application, including each patient’s baseline health,
comorbidities, and tissue composition, to fully
obtain the benets of these devices and avoid
complications by using the tailored stapling
products available for each clinical situation.
Take-Home Messages
• Tissue depth and composition must be
taken into consideration when choosing
staple size.
• It is important to avoid torque on the tissues when ring staplers.
• Surgeons should become familiar with
stapling devices and their possible complications despite the relative ease of
operating they provide.
References
1. Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T,
Serveld M.The science of stapling and leaks. Obes
Surg. 2004;14:1290–8.
2. Klimczak A, Miroslawska-Kempinska B, Mik M,
Dziki A. Evolution of the mechanical suture. Pol
Przegl Chir. 2013;85:44–6.
3. Olah A.Aladar Petz, the inventor of the modern surgical staplers. Surgery. 2008;143:146–7.
4. Robiscek F, Konstantinov I.Humer Hultl: the father
of the surgical stapler. J Med Biogr. 2001;9:16–9.
5. Steichen FM, Ravitch MM. Mechanical sutures in
surgery. Br J Surg. 1973;60:191–7.
6. Kleineld NR. U.S. Surgical’s checkered history.
NewYork Times. May 13, 1984.
7. Chekan E, Whelan RL.Surgical stapling device-tissue
interactions: what surgeons need to know to improve
patient outcomes. Med Devices. 2014;7:305–18.
8. Ravitch MM, Steichen FM. Technics of staple
suturing in the gastrointestinal tract. Ann Surg.
1972;175:815–35.
9. Nakayama S, Hasegawa S, Hida K, Kawada K, Sakai
Y. Obtaining secure stapling of a double stapling
anastomosis. J Surg Res. 2015;193:652–7.
10. Nguyen NT, Dakin G, Needleman B, Pomp A, Mikami
D, Provost DA, Scott DJ, Jones DB, Gallagher S,
Gagner M, Murr M. Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a
multicenter prospective randomized trial. Surg Obes
Relat Dis. 2010;6:477–84.
11. Sakran N, Assalia A, Sternberg A, Kluger Y, Troitsa
A, Brauner E, Van Cauwenberge S, De Visschere M,
Dillemans B.Smaller staple height for circular stapled
gastrojejunostomy in laparoscopic gastric bypass:
early results in 1,074 morbidly obese patients. Obes
Surg. 2010;21:238–43.
12. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda
Y, Saito N.Relationship between multiple numbers of
stapler rings during rectal division and anastomotic
leakage after laparoscopic rectal resection. Int J Color
Dis. 2008;23:703–7.
13. Lee S, Ahn B, Lee S.The relationship between the
number of intersections of staple lines and anastomotic leakage after the use of a double stapling
technique in laparoscopic colorectal surgery. Surg
Laparosc Endosc Percutan Tech. 2017;27:273–81.
14. Steichen FM, Ravitch MM. Mechanical sutures in
esophageal surgery. Ann Surg. 1980;191:373–81.
15. Kim H, Jang J, Son D, Lee S, Han Y, Shin YC,
Kim JR, Kwon W, Kim S. Optimal stapler cartridge selection according to the thickness of the
pancreas in distal pancreatectomy. Medicine.
2016;95(35):e4441.
16. Nakamura M, Ueda J, Kohno H, Aly MYF, Takahata
S, Shimizu S, Tanaka M.Prolonged peri-ring compression with a linear stapler prevents pancreatic
stula in laparoscopic distal pancreatectomy. Surg
Endosc. 2011;25:867–71.
17. Okano K, Oshima M, Kakinoki K, Yamamoto N,
Akamoto S, Yachida S, Hagiike M, Kamada H,
Masaki T, Suzuki Y.Pancreatic thickness as a predictive factor for postoperative pancreatic stula after
distal pancreatectomy using an endopath stapler. Surg
Today. 2013;43:141–7.
18. Tsukane M, Kobayashi Y, Otsuka Y, Maeda T,
Yamazaki N, Watanabe H, Ando T, Kaneko H, Fujie
MG.Effect of the thickness and nonlinear elasticity
of tissue on the success of surgical stapling for laparoscopic liver resection. Conf Proc IEEE Eng Med Biol
Soc. 2014;2014:353–6.
19. Yao D, Wu S.Application of stapling devices in liver
surgery: current status and future prospects. World J
Gastroenterol. 2016;22:7091–8.
20. Odabasi M, Muftuoglu MAT, Ozkan E, Eris C, Yildiz
MK, Gunay E, Abuoglu HH, Tekesin K, Akbulut
S.Use of stapling devices for safe cholecystectomy in
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21. Aoki T, Ozeki Y, Watanabe M, Tanaka S. Cartilage
folding method for main bronchial stapling. Ann
Thorac Surg. 1998;65:1800–1.
22. Timucin A, Aras O, Karip B, Memisoglu K.Staple
line reinforcement methods in laparoscopic sleeve
gastrectomy: comparison of burst pressures and leaks.
JSLS. 2015;19:e2015.00040.
23. Al HGN, Haddad J. Preventing staple-line leak
in sleeve gastrectomy: reinforcement with bovine
pericardium vs. oversewing. Obes Surg. 2013;23:
1915–21.
24. Mery CM, Sha BM, Binyamin G, Morton JM,
Gertner M.Proling surgical staplers: effect of staple
height, buttress, and overlap on staple line failure.
Surg Obes Relat Dis. 2008;4:416–22.
25. Shikora SA, Mahoney CB.Clinical benet of gastric
staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25:1133–41.
26. Taha O, Abdelaal M, Talaat M, Abozeid M. A randomized comparison between staple-line oversewing
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Fundamentals ofDrain
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Management
GuillaumeS.Chevrollier, FrancisE.Rosato,
andErnestL.Rosato
11
11.1 Introduction
11.1.1 General Concepts
The types, indications, and placement of drains
are often confusing to the surgical trainee. In
general, surgical drains are placed to evacuate
an unwanted collection of uid, blood, or air.
Intraoperatively, drains are placed to drain
infected areas and potential spaces at risk for
uid accumulation and secondary infection. As
a general rule, drains should never be placed
with the goal to drain blood, as hemostasis
should be achieved by the completion of any
case. Drains are also commonly utilized to
decompress hollow organs such as the stomach
and bladder during the perioperative recovery
period when paralytic ileus or close monitoring
needs are common. Specialized drains placed
in the GI tract can serve to decompress segments of bowel, preventing anastomotic dehiscence. Additionally, they can help control
potential areas of stula formation from the
liver, biliary tree, and pancreas. Specialized
genitourinary drains, such as the percutaneous
G. S. Chevrollier · F. E. Rosato · E. L. Rosato (*)
Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University,
Philadelphia, PA, USA
e-mail: Ernest.Rosato@jefferson.edu
nephrostomy tube and the suprapubic catheter,
have been developed to decompress the
obstructed kidneys and bladder, respectively.
When widespread soilage and peritoneal contamination from a perforated viscus occur, specialized drains are indicated through which
irrigation and drainage can be obtained.
Recently, the use of intraoperatively placed
drains has been associated with higher rates of
postoperative deep space infection and stula
formation, calling into question their use in
routine surgical procedures.
Although evidence is relatively lacking outside of plastic and breast surgery, some surgeons
advocate for the use of continued antibiotic prophylaxis for the duration of certain postsurgical
drains [1].
11.1.2 History oftheSurgical Drain
The origins of the surgical drain can be traced
as far back as 400 BC, specically to
Hippocrates, who rst reported the use of cloth
and small tubes to drain infected spaces. For
centuries, passive drainage with makeshift
tools persisted, using such materials as animal
bones, catgut, horsehair, cloth, glass, and metal
tubing. Passive drainage remained the only
form of operative drainage until the end of the
nineteenth century, when William Halstead
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_11
143
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popularized the radical mastectomy. By raising
skin aps during the mastectomy, a large
potential space was created, which inevitably
lled with uid and often required re- operative
drainage. It wasn’t until 1947, when a general
surgeon named David Murphey applied suction
to a perforated drain, that a successful postmastectomy drainage device became available.
Although Murphey’s system allowed only for
intermittent suction, rapid improvements and
modications over the next decade would
allow for the application of continuous suction
to the surgical drain. Over the ensuing years,
various modications have allowed the modern
surgeon to overcome such basic barriers as
drain clogging and collapse, leading to the vast
number of surgical drains and drainage systems available today [2].
11.1.3 Drain Sizes
Drains are typically described in terms of their
size either on the French scale or the gauge
system.
11.1.3.1 The French Scale
Surgical catheters are generally sized using the
French (Fr.) scale, which is a direct measure of
the catheter’s outer diameter. By denition, the
size in French is equal to three times the catheter’s external diameter in millimeters (mm), as
demonstrated by the equation below:
Fr where outer diameter in mm.,
3 dd
For example, a 3 Fr. catheter has an outer
diameter of one millimeter, a 6 Fr. catheter has
an external diameter of 2 mm, and so on.
Practically speaking, the French size is a close
approximation of the catheter’s outer circumference in millimeters, where a 10 Fr. catheter
has an outer circumference of approximately
10mm and a 20 Fr. catheter has an outer circumference of approximately 20 mm. It is
important to note again that the French size is
reective of a catheter’s OUTER circumference, and because the intraluminal diameter
depends mainly on wall thickness, the French
Table 11.1 The French scale and gauge system
French scale Gauge scale
French
size
3 1 32 0.24
4 1.33 30 0.31
5 1.67 28 0.36
6 2 27 0.41
7 2.33 26 0.46
8 2.67 24 0.56
9 3 23 0.64
10 3.33 22 0.71
11 3.67 21 0.81
12 4 20 0.90
13 4.33 19 1.07
14 4.67 18 1.27
15 5 17 1.47
16 5.33 16 1.65
18 6 15 1.83
20 6.67 14 2.11
24 8 13 2.41
28 9.33 12 2.77
30 10 11 3.05
32 10.67 10 3.40
Outer diameter
(mm)
Needle
gauge
Outer diameter
(mm)
size is not reective of intraluminal size or
ow rate [3].
11.1.3.2 The Gauge System
The other commonly used scale is the gauge system, which also measures the outer diameter of a
needle, catheter, or drain, and is generally
reserved for describing the size of hypodermic
needles. This scale was initially developed for
wire manufacturing and is mathematically much
less intuitive than the French scale. On the French
scale, a rising value corresponds to a larger catheter or tube size. By contrast, the gauge system
has an inverse relationship between gauge and
size, where a higher gauge corresponds to a
smaller catheter size (Table11.1) [3, 4].
11.2 Technical Considerations:
Drain Types
There are four common classes of drains: open
drains, closed drains, closed drains with suction,
and sump drains—with and without irrigation.
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11.2.1 Open Drains
Open drains are the oldest and simplest type of
surgical drain. These drains are placed into a collection or open wound and drain either across a
pressure gradient or with the assistance of capillary force to the outside environment, where the
drained uids usually collect in an absorbenttype dressing. The presence of the drain also prevents skin closure or wound healing over the
deep tissue space, allowing for healing by secondary intention and prevention of abscess formation or recurrence. Since the system is open to
the environment, this type of drainage system is
not sterile and is by denition considered contaminated. Examples of common open drains
include wound wicks, gauze wound packing,
Penrose drains, and setons. These drains are commonly used in heavily contaminated surgical
cases to prevent or treat a closed space infection.
145
11.2.2 Closed Drains
Closed drainage systems utilize a perforated
drainage catheter, which is connected to a drainage receptacle via a closed tubing system. The
entire system is isolated from the external environment and is better protected from external
bacterial contamination. The drained uids move
from the higher pressure (intra-abdominal) or tissue space to the lower pressure (external environment). Drainage is often facilitated by movement,
cough or strain, which create a pressure gradient
to direct ow externally. These drains are utilized
by surgeons and interventional radiologists for
the drainage of postoperative uid collections
and for viscus decompression. Some examples of
closed drains are discussed below.
11.2.2.1 The Pigtail Catheter
The most common interventional radiology (IR)
drain is the pigtail catheter, which must be
inserted percutaneously under direct radiologic
supervision. Specically, the pigtail catheter is
placed using the Seldinger technique over a wire
to guide the drain to its desired location. Once the
drain is in correct position, the guidewire is
Fig. 11.1 Pigtail catheter with coiling, locking tip
removed, allowing the distal end of the catheter
to coil onto itself and form a locking tip, or “pigtail,” that allows it to remain inside a collection
(Fig.11.1).
11.2.2.2 Hollow Viscus Drains
Surgeons may also utilize closed drainage systems intraoperatively to decompress a hollow
viscus which may have a tenuous suture closure
and high risk of postoperative leak into the
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abc
G. S. Chevrollier et al.
Fig. 11.2 Hollow viscus drains with different retention mechanisms. (a) Mushroom catheter. (b) Malecot catheter.
(c) Foley catheter with balloon tip
peritoneal cavity. These types of tubes are often
used to decompress the biliary tree (T-tubes),
gallbladder (mushroom catheter or Malecot catheter) (Fig.11.2a, b), stomach (gastrostomy tube
or G-tube) (Fig.11.3), duodenal stump (duodenostomy tube or D-tube), and genitourinary tract
(Foley catheter, suprapubic catheter, and percutaneous nephrostomy tube) (Fig. 11.2c). These
drains have anges, extensions, or balloons
which help with drainage and retention within
the lumen (Fig. 11.2). They are usually constructed from soft rubber or silicone and therefore collapse and fail to drain if strong suction is
applied. Prolonged use can lead to a permanent
stula from the hollow viscus to the skin, which
may require surgical closure.
11.2.2.3 Gastric Tubes
Special consideration should be given to the gastrostomy tube (G-tube), a very common yet often
mismanaged drain. Although G-tubes can be
placed for palliative decompression, they are
more often used for long-term enteral feeding
access. G-tubes allow for both decompression of
the stomach by opening it to a drainage bag and
“venting” and for feeding by injecting tube feeds
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Fig. 11.3 Gastric tubes.
(a) Percutaneous
endoscopic gastrostomy
(PEG) tube. (b) MIC G
tube (Halyard Health,
Inc., Alpharetta, GA)
®
a
Skin bumper
b
Skin bumper
Intraluminal
flange
Intraluminal
balloon
directly into the stomach. G-tubes mainly come
in one of two forms: the percutaneous endoscopic
gastrostomy (PEG) tube or the MIC G® tube
(Halyard Health, Inc., Alpharetta, GA), the main
difference being the presence of a ange or a balloon at the intracorporeal extremity of the catheter (Fig.11.3).
11.2.2.4 The PEG andtheMIC G-tubes
With endoscopic assistance, the PEG tube is
advanced down the esophagus and into the stomach. Under direct endoscopic visualization, the
tube is externalized by pulling it through the gastric wall, abdominal wall, and overlying skin. A
plastic ange at the proximal end of the tube is
used to pull the gastric wall up to the abdominal
wall and locked in place with a bumper applied to
the skin surface (Fig. 11.3a). Within approximately 14–21 days, the tract epithelializes and
the stomach scars to the abdominal wall, making
bedside tube removal or exchange generally safe
thereafter. Once deemed appropriate for removal,
the surgeon simply pulls on the tube with enough
force to dislodge the gastric ange through the
tract and out through the skin. Once the PEG is
removed or dislodged, it cannot be replaced into
the tract, as the proximal ange cannot t back
into the tract. If replacement is desired and as
long as the tract is well established, a MIC G-tube
can be reinserted. This tube is designed like a
Foley catheter with a balloon at the tip. This
design allows the introduction of the catheter
from the skin, bypassing the need for endoscopy.
Subsequent ination of the balloon secures the
tube within the gastric lumen (Fig.11.3b). As is
the case with Foley catheters, it is important to
remember that the balloon should only be lled
with water and never with saline. Over time,
saline will precipitate to form salt crystals that
can perforate the balloon or clog the lumen of the
side port, preventing deation of the balloon.
11.2.2.5 Troubleshooting theG-tube
Two very common issues arising in patients with
G-tubes are dislodgment and obstruction. If the
tube falls out of its tract after the 14–21-day
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mark, a Foley catheter may be placed safely in
the tract to prevent it from closing or narrowing
until a new tube can be placed. For elderly or
malnourished patients, it can take up to 4–6weeks
for the tract to mature. Once replaced, correct
position can be conrmed with simple auscultation of air injected into the stomach. Although
often unnecessary, placement can also be conrmed at the bedside by injecting contrast into
the G-tube and obtaining an abdominal X-ray.
Visualization of the gastric rugae conrms adequate placement.
Another common problem encountered is
occlusion of the G-tube, often from administration of improperly crushed or dissolved medications or precipitation of tube feeds. Generally,
this can be resolved by applying gentle positive
pressure with warm water into the obstructed
lumen. If this fails, instilling a 50:50 mixtures of
orange juice and soda and allowing it to percolate
within the tube for 30minutes often breaks up the
occlusion. Pancrelipase solution has also been
reported as an effective clog- busting agent.
Finally, if this fails, a specially designed de-clogging brush can be used; however, this is associated with a risk of damage to the tube and even to
bowel if improperly used. The same unclogging
principles can be applied to the more temporary
Dobhoff tubes, which are thin, single lumen catheters that are strictly used for feeding. Dobhoffs
travel from the nose to either the stomach (nasogastric) or to the duodenum (nasoduodenal) if
post-pyloric feeding is desired.
11.2.2.6 T-tubes
Another noteworthy tube with which the surgical
trainee must gain familiarity is the T-tube
(Fig.11.4), which is most commonly used as a
platform for biliary tree reconstruction and biliary anastomoses, as well as for decompression of
biliary strictures and blockages. A T-tube is
designed in the shape of the letter T, with the
longer end of the tube (the base of the T) extending from the biliary tree to the external environment. The two shorter ends (top of the T) lie
within the biliary tree at the site of anastomosis
or repair. When removal is appropriate, a T-tube
cholangiogram can be performed to ensure that
G. S. Chevrollier et al.
Fig. 11.4 T-tube
there is no intra-abdominal extravasation of contrast, conrming an intact and well-healed biliary
tree. A number of modications can be made to
the T-tube intraoperatively to facilitate placement, optimize ow within the tube, minimize
trauma to the biliary tree, and avoid a postremoval bile leak. The rst option is to incise the
T-tube along the length of its intraluminal portion
(Fig.
11.5b). A second option is to cut a “gutter”
along this same intraluminal portion of the T-tube
(Fig.11.5d). Others prefer to create a “notch” in
the segment of the drain that sits directly across
from the draining lumen at the top of the T
(Fig. 11.5e). These modications allow the
T-tube to fold on itself more easily with traction,
facilitating removal. With all of these modications, the intraluminal ends can also be beveled to
facilitate insertion (Fig.
11.5c).
11.2.3 Closed Suction Drains
Closed suction drains are among the most
commonly used drains in the surgeon’s armamentarium. These are classically utilized to drain
potential spaces left after an extirpative procedure or infected spaces and abscesses. They also
play a role in the management of high-risk anastomoses, where a controlled stula may be
preferable to returning to the OR for revision
or where there are limited revision options
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