Drainage of Abdominal Surgery
Drainage of Abdominal Surgery
Drainage of Abdominal Surgery
Received: April 11, 2022 The application of various drains has been a part of the surgical activity since
ancient times. Today’s modern surgery chooses drainage itself and drainage systems
Published: April 27, 2022 according to clear criteria and purpose. The most used sizes of drains were found to
be 28F, 32F and 36F in adults and 16F, 20F and 24F in children. The most important
criteria for drain selection are drainage efficiency (performance), biostability and
Citation: Marián Bakoš, Michal Kuťka. biocompatibility. Drainage systems are a common part of postoperative surgical
Drainage in Abdominal Surgery. Biomed management and are used to remove fluid collection from the abdominal cavity.
J Sci & Tech Res 43(3)-2022. BJSTR. When draining the peritoneal cavity, it is necessary to be aware of the most common
MS.ID.006912. places of fluid accumulation. Abdominal drainage is not easy, especially due to more
complicated anatomical conditions and the presence of consciousness and intestinal
Keywords: Drains; Drainage; Abdominal
loops. The aim of this review was to evaluate the evidence supporting the systematic
Surgery; Intra-Abdominal Drains
use of abdominal drainage.
Introduction
• They have a restituting effect [1].
Since ancient times, surgical procedures have been associated
with conditions, that have either the cause, or effect of evacuating Characteristics of Drainage Systems and their
liquid media, that are detrimental to the body. To achieve this effect, Effectiveness
various devices, which fall under the collective name “drains”, have The shape of the drains can be straight or shaped. Curved drains
been gradually designed, described, and used. We call the drain a are used in thoracic surgery, where they are applied after surgery
simple or more com-plicated aid or a whole system used to evacuate on the diaphragm. The end of the drain that remains outside the
unwanted fluids from the body [1]. The application of various drains body can be either funnel-shaped to connect to the connector
has been a part of the surgical activity since the days of Hippocrates, (inserted from the outside) or beveled for easier passage through
when various metal, bone, gauze or wick preparations and gauze the chest wall (inserted during internal surgery) [3]. Drains are
combinations were used as means of passive drainage. The oldest manufactured in various lengths and widths. The width of the drain
record of the usage of drainage comes from Hippocrates himself can be marked either by a number according to the Charrier scale,
(480-377 BC). He used a wooden tube to drain the empyema [2]. or the so-called French units. On the Charrier scale, the number 1
Today’s modern surgery is more advanced and precise - it chooses is equal to 0.3 mm and each subsequent number is 0.3 mm larger
drainage itself and drainage systems according to clear criteria and (Figure 1) [2]. The most used sizes were found to be 28F, 32F and 36F
purpose: in adults and 16F, 20F and 24F in children. Polyethylene catheters
• They remove pathological liquid products (purulent fluids, (Intracarth), “J” -shaped catheters are intended for neonatal age [4].
intestinal contents, effusion, etc.) When choosing the size of the lumen of the drain and the various
couplings, it is necessary to proceed from the laws applicable to the
• They remove loose intra-abdominal fluids (bile, pancreatic
dynamics of gases and fluids. Poiseuille’s equation is assumed for
juices, lavage fluids) before they can cause complications.
the gas flow under the assumption of laminar flow. The air flow is
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34642
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
directly proportional to the square of the drain radius. For humid 2. Drainages with a square cross-section at the beginning of
air, which has a turbulent flow, the Fanning equation applies, and the stream show approximately the same volume flow when
so the flow rate depends on the radius of the drain up to the fifth compared to drains of circular cross-section with the same
power of the radius [5]. cross-sectional area size.
4. With the same geometry, the larger the volume flow, the more
side holes of the same size are located on the drain.
5. As the ratio of the sum of the areas of the side openings to the
cross-section of the collecting channel increases, the drainage
capacity increases [7].
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34643
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
activity participate in locomotion, participate in ventilation, etc. are greater in the right hypochondria due to the position of the
When draining the peritoneal cavity, it is necessary to be aware of liver than in the left. Data on intra-abdominal pressure in the early
the most common places of fluid accumulation (Figure 2). In the postoperative period after laparotomy are interesting. While the
vertical position, the lowest stored area of the abdominal cavity is intra-abdominal pressure is around 2 kPa on the first postoperative
the Douglas space, in the horizontal position the subphrenic space day, the fourth postoperative day can reach up to 6 kPa (61.2 cm
on both sides and also the Douglas space [9]. H2O). Changes in intra-abdominal pressure also occur during
artificial lung ventilation and are reflected in a higher incidence of
In the vertical position, the lowest stored area of the abdominal
laparoscopic wound dehiscence. Based on a number of experimental
cavity is the Douglas space, and in the horizontal position the
and clinical studies in the 1990s, intra-abdominal hypertension
subphrenic space on both sides and also the Douglas space. The
has been shown to cause abdominal compartment syndrome,
circulation of fluid between these three spaces is given by the intra-
which is often observed in clinical patients and in patients after
abdominal pressure and the gravity of the fluid (Figure 3). The
severe abdominal trauma [11,12]. An increase in the content of the
activity of the abdominal muscles is reflected in the change in intra-
abdominal cavity as well as the retroperitoneum contributes to the
abdominal pressure. In addition to muscle contraction, the increase
increase of intra-abdominal pressure. Intra-abdominal pressure is
in intra-abdominal pressure may be caused by acute visceral
transmitted to adjacent areas and has adverse effects on cardiac
distension [9,10]. The resting intra-abdominal pressure in the
output, pulmonary ventilation, renal function, and cerebrospinal
horizontal position reaches values in the range of 0.78-1.5 kPa (8-
pressure. Increasing intra-abdominal pressure has an adverse
15.3 cm H2O). At the stand, the pressure increases due to gravity up
effect on visceral perfusion. The more the intra-abdominal pressure
to 2.94 kPa at the bottom of the Douglas space. During respiration,
increases and the longer this increase lasts, the more the blood flow
the intra-abdominal pressure changes by about 0.4 kPa, but with
through the splanchnic area decreases, which is reflected in the
a severe cough, it can reach values of up to 14.7 kPa (150 cm H2O)
lowering of the pH of the intestinal mucosa [13].
[10]. The pressure changes resulting from respiratory movements
Figure 3: Directions of possible fluid propagation in the abdominal cavity (left) Areas where fluid usually accumulates (right)
a) a - Subhepatic space,
b) b - Subphrenic space on the right,
c) c1, c2 - Subphrenic space on the left,
d) d - Paracolic space on the left,
e) e - Douglas space.
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34644
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
Drains established near anastomoses can be the first to inform Figure 5: Drainage after stomach surgery Left - subtotal
resection of the stomach Right - gastrectomy with
us about possible suture insufficiency - signal drains. Active
subsequent oesophagoyjuananastomosis with reservoir
drainage is usually not recommended near anastomoses. The formation.
most commonly used closed drainage system in visceral surgery
is Robinson drainage (Figure 4), which consists of a 20F silicone Based on a German questionnaire survey, Böhm found out that
hose with a length of one meter. The end, which is placed in the 90% of them would introduce drainage after gastrectomy. Drains
abdominal cavity, has several holes on the sides and the opposite are most often established in the area of anastomoses, subhepatic
end is connected to a plastic calibrated bag with a volume of 350 space or in the area of the duodenal stump. The average length of
ml. This system is modern and highly hygienic, it also contains drainage was 5.5 days. The suture of the ulcer was always sealed
a shut-off valve that does not allow ascending infection [16]. with a suture [17]. Drainage of the duodenal stump area depends on
Infectious complications associated with bacterial contamination the anatomical conditions, the type of disease, the complexity of the
of the drain are one of the most important risk factors for intra- resection and the type of duodenal stump closure. If the operating
abdominal drainage. Gastric surgery, such as early suture and ulcer surgeon is in doubt, then he drains the duodenal stump area always
sealing, gastric resection BI or BII, vagotomy, require drainage of sufficiently and effectively. The prognosis of early dehiscence of the
the operating room. If a drain is laid, then it usually slopes into the duodenal stump is a very serious complication with high lethality
subhepatic space or Redon’s drain (Figure 5). - up to 50% [18]. After the patient’s condition improves, the fistula
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34645
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
usually heals spontaneously. The abdominal cavity is still secured are chosen - usually No. 12. It is led out of the perineum forward
by laying a slope drain under the liver. so that the patient does not lie on them. Miles initially closed the
perineal wound primarily. Active drainage was not yet known, and
Use of Drainage in Small and Colon Surgery
ascending infections arose from the catchment drainage. Miles
In simple resections of the small intestine (Meckel’s solved this by introducing open aftercare in the form of so-called
divertuculus), drains are usually not established. In the case of “packing” - longs placed in a thin foil. The healing process was very
acute small bowel surgery, e.g., due to Crohn’s disease, then it lengthy. Secondary healing is always very unpleasant for the patient.
always drains. The most common indications for surgical treatment Today, this method is no longer used, and after rectal extirpation,
in Crohn’s disease are complications in terms of fistulations, primary closure of the perineal wound is always indicated. Active
especially in the ileocecal region [19]. Abdominal drainage after drainage is started at the end of the operation.
colorectal operations depends on the type of operation (acute,
elective) and the scope of the operation. It is not recommended that
the drain lean against the intestinal wall (Figure 6). The abdominal
cavity drains only in cases of major damage to the serous surface
of the intestinal wall or exposure of the lymphatic system in the
retroperitoneum. In these cases, drainage is established in the
area after the resected colon ascendens and/or in the Douglas
space, usually for 48-72 hours. Drainage is always recommended
for operations on the left half of the colon and rectum, even if no
positive effects of prophylactic drainage after colonic elective
procedures have been found in control studies [20]. In the case of
rectal amputations, it is advantageous to introduce Redon drainage
into the resulting cavity through the perineum. Usually, two drains
are introduced. Böhm and co-workers report that 90% of surgeries
in Germany drain the abdominal cavity after resections of the
esophageal loop. They usually drain the Douglas area (54%) or the
anastomosis area (31%). The average length of drainage was 5.6
days [17]. Figure 7: Drainage after low rectal reaction. Drain taken
retroperitoneally.
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34646
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34647
Volume 43- Issue 3 DOI: 10.26717/BJSTR.2022.43.006912
location has drainage success, especially when stored in preformed 12. Papavramidis TS, Marinis AD, Pliakos I, Kesisoglou I, Papavramidou
N (2011) Abdominal compartment syndrome - Intra-abdominal
areas or near parenchymal organs, to minimize the possibility of
hypertension: Defining, diagnosing, and managing. Journal of
clogging with momentum or intestinal loops. Due to the nature of Emergencies, Trauma, and Shock 4(2): 279291.
the effusion that is resolved by abdominal drainage, the expected 13. Carlotti AP, Carvalho WB (2009) Abdominal compartment syndrome: A
drainage fluid content, and other factors, in addition to the simple review. Pediatr Crit Care Med 10(1): 115-120.
tubular drain after abdominal surgery, other drainage systems are 14. Domínguez Fernández E, Post S (2003) Abdominal drainages. Chirurg
used, as mentioned above. 74(2): 91-98.
15. Durai R, Mownah A, Philip CH Ng (2009) Use of drains in surgery: a
References review. Journal of Perioperative Practice 19: 180-186.
1. Ramesh BA, Jayalakshmi BK (2021) Suction Drains. StatPearls. Treasure 16. Böhm B, Neudecker J, Ruff J, Műller JM (1998) Zuganswege und
Island (FL): StatPearls Publishing. Drainagen bei konventioneller Cholezystektomie, Gastrektomie und
2. Puleo FJ, Mishra N, Hall JF (2013) Use of intra-abdominal drains. Clinics Sigmaresektion. Ergebnisse einer Umfrage an deutchen Kliniken.
in Colon and Rectal Surgery 26(3): 174–177. Viszeralchirurgie 33: 316-324.
3. Durai R, Mownah A, Philip CH N (2009) Use of Drains in Surgery: A 17. Cozzaglio L, Cimino M, Mauri G, Ardito A, Pedicini V, et al. (2011)
Review. Journal of Perioperative Practice 19(6): 180-186. Percutaneous transhepatic biliary drainage and occlusion balloon in
the management of duodenal stump fistula. J Gastrointest Surg 15(11):
4. Chestovich PJ, Jennings CS, Fraser DR, Ingalls NK, Morrissey SL, et al. 1977-1981.
(2020) Too Big, Too Small or Just Right? Why the 28 French Chest Tube
Is the Best Size. J Surg Res 256: 338-344. 18. Richards RJ (2011) Management of abdominal and pelvic abscess in
Crohn’s disease. World journal of gastrointestinal endoscopy 3(11):
5. Ostadfar A (2016) Chapter 1 - Fluid Mechanics and Biofluids Principles. 209-212.
Biofluid Mechanics, p. 1-60.
19. Thiede A, Engemann R, Imhof M (1993) Drainagetechniken und
6. Smith SR, Connolly JC, Crane PW, Gilmore OJ (1982) The effect of surgical Drainageprinzipien in der visceralen Chirurgie, Chirurg 64: 90-95.
drainage materials on colonic healing. Br J Surg 69: 153-155.
20. Beattie G, A Siriwardena A (2000) Bacterial infection and extent of
7. Černý J (1992) A kolektív: Špeciálna chirurgia II.-deli, Chirurgia brušných necrosis are determinants of organ failure in patients with acute
orgánov a retroperitonea, I. vydanie, Martin, Dérerova zbierka, Osveta, necrotizing pancreatitis. British Journal of Surgery 87(2): 1020-1024.
pp. 105-779.
21. De Filippo M, Puglisi S, D’Amuri F, Gentili F, Paladini I, et al. (2021) CT-
8. Čapov I, Weschler J (2001) Drény a jejich využití v chirurgických oborech. guided percutaneous drainage of abdominopelvic collections: a pictorial
Czech : 1. Vyd. essay. La Radiologia medica 126(12): 1561-1570.
9. Čihak, Radomír a Miloš GRIM (2013) Anatomie. 2. 3. vydání. Praha 22. Malkov IS, Shaĭmardanov R Sh, Zaĭnutdinov AM, Birial’tsev VN, Lustina
: Grada. NI (2002) Laparoscopic sanitation of the abdominal cavity in combined
treatment of peritonitis. Khirurgiia (Mosk) (6): 30-33.
10. Pavel Petrovický (2001) Anatomie s topografií a klinickými aplikacemi
(I. svazek). Martin. Osveta, pp. 463. 23. Beger HG, Isenmann R (1999) Surgical management of necrotising
pancreatitis. Surg Clin North Am 79(4): 783-800.
1. Newman RK, Dayal N, Dominique E (2021) Abdominal Compartment
Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing
2022.
11. Schein M, Wittmann DH, Aprahamian CC, Condon RE (1995) The
abdominal compartment syndrome: the physiological and clinical
consequences of elevated intra-abdominal pressure. J Am Coll Surg
180(6): 745-753.
ISSN: 2574-1241
Assets of Publishing with us
DOI: 10.26717/BJSTR.2022.43.006912
Marián Bakoš. Biomed J Sci & Tech Res • Global archiving of articles
• Immediate, unrestricted online access
This work is licensed under Creative • Rigorous Peer Review Process
Commons Attribution 4.0 License
• Authors Retain Copyrights
Submission Link: https://biomedres.us/submit-manuscript.php
• Unique DOI for all articles
https://biomedres.us/
Copyright@ Marián Bakoš | Biomed J Sci & Tech Res | BJSTR. MS.ID.006912. 34648