More about use of drains in surgery

drains in surgeryI would love to be able to find all the good answers about drains in surgery from the literature, but alas there is not so much to find. There is about testing drains (comparing them or devising methods), and quite a few CRTs in recent years which show that gallbladders, appendices, thyroids, liver resections etc do not need drainage.

The drain is one of the surgeons closest friends, some use them always others rarely, and it should not be that way if the literature already had the answers to the problems. Just make a simple decision matrix by asking two primitive questions.

1. Will a drain prevent the problem?

2. Will a drain alone solve the problem should it occur?

Postoperative bleeding. The answer is no to both questions.

Wide skin dissection (mastectomy, incisional hernia). Objective to prevent seroma and infection. The answer may be yes to the second question for the seroma. About infection I doubt it.

Skin and soft tissue abscess. Objective to prevent recurrence. A wide skin incision and curretage and irrigation is all it takes. I do not know of any trial that has tested the issue. How many still put in drains for an anal abscess? It is very uncomfortable for the patient and in my experience does no good. Therefore no to both questions above.

Drainage of an anastomosis. The objective relates to anastomotic dehiscens. The answer is no to the first question, and nearly always no to the second.

Drainage of diffuse peritonitis. The objective is prevention of abscess. This is one of the most common reasons for drains. Price showed in 1905 that drains are of doubtful value. There are probably more than 30 scientific papers which aimed to show that a bunch of drains and irrigations is the way to go. They were wrong, it seems. See all the pictures shown on meetings and courses to understand that this praxis is still a fundamental part of most surgeons thinking about drains and peritonitis. I am unaware of any trial that has tested the issue. Those of us who were taught to use drains and then have stopped using drains for diffuse peritonitis would probably all respond that the answer to the questions above is no on both accounts.

Operations for appendicitis or acute cholecystitis or acute diverticulitis. Objective to prevent abscess. There was a time when most surgeons would put in a drain. It came out of fashion for appendicitis and most surgeons today do not drain appendicitis, even perforated appendicitis. I believe there are a couple of trials that showed no benefit of drains in appendicitis. But I would think that many surgeons still put in drains for acute cholecystitis and diverticulitis. Those who have stopped doing so would answer no to both questions above.

Operative drainage of an abdominal abscess cavity. Objective to prevent recurrence. This is a question for some thought. Take the the experience from several published series on percutaneous drainage. It is a beatiful method. But there is no answer to how long the drain should be retained. Is it sufficient to just empty the cavity of pus and draw the drain? I believe it is, because it decompresses the focus and allows the tissue pressure to collaps the cavity. I would love to see a trial comparing immediate withdrawel of the drain versus drainage for ten days. My guess is that prolonged drainage does not prevent recurrent abscess.

In operative abscess drainage I do not put in drains because the abscess cavity is no longer in existence after the operation, I have disrupted it. It is true for abscesses in Crohn’s, in diverticulitis, bowel perforations, or anastomotic abscess. The only time I consider a drain is in pelvic abscess because the cavity will not be able to collaps. So sometimes I put in a drain for such an absess but usually I prefer to reoperate (transanally) should the abscess recurr, bacause my experience is that the drain does not prevent recurrence. This line of thought is probably true also for pleural empyema.

I did not support my views with any reference to literature at all. Why? I like to think that surgeons do sensible things. They will abandon drains when there no longer is a need for them. The way I practice surgery today is different from when I began. In that process drains have lost their importance for reasons I cannot fully explain. The clinical trials have been important but only so much.

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