Everything you always wanted to know about surgical drains...but were afraid to ask!

Clinical Case

Open Drains – These drains empty directly to the exterior into the overlying wound dressings or stoma bag. The corrugated rubber drain, Penrose, gauze wick drain and glove finger drain are examples of this type of drain. They are mostly used in superficial wounds and cavities. Drained fluid collects in a gauze pad or stoma bag wick which can be be changed. They are simple and easy to apply. However, it is often difficult to measure the effluent and they have high rate of wound infection.

Closed drains – These are hollow tubes of varying materials brought out through a body orifice or stab wound and are connected to a closed system of a sterile drainage bag. This drain is mostly used in deep cavities. The risk of surgical wound infection is less and effluent can be easily being collected and measured.

The opening in the abdominal wall for these drains should be made large enough, as passive drains are potentially collapsible. Easy Flow drains have intraluminal corrugations to prevent complete collapse (inlay). Passive drains cannot be sealed and are open systems with the potential risk of retrograde infections.

The Jackson-Pratt drain is oval-shaped with numerous orifices and intraluminal corrugations (inlay). The Blake drain has four channels along the sides with a solid core center.

Silicone or Silastic tubes are less reactive than  other types of drains. They are less prone to becoming plugged as a result of clotting serum. Because of the soft texture of silicone, erosion into the intestine is uncommon. A disadvantage of silicone drains is their lack of reactivity; hence, there is minimal fibrous tract formation. 

Rubber Tube Drain -These are also passive drains, but are tubular and more rigid than the Penrose drain. Both polyethylene and rubber tube drains establish tracts to the outside, as they are mildly irritating and stimulate adhesion formation. They effectively evacuate air and serum from the pleural cavity and bile from the common bile duct (so a chest tube, or a T-tube, would be examples of such drains). Drainage tract infection following the use of tube drains is rare. One of the disadvantages of rubber and polyethylene tubes is that they become clogged with clotted serum or blood unless they are large.

Sump drains are usually double-lumen tubes with a larger outflow lumen and a smaller inflow “sump” lumen. The larger lumen is connected to a suction system and evacuates intra-abdominal secretions. The smaller lumen serves as a venting tube, allowing air to enter the larger lumen. This principle should help to break the vacuum in the large draining tube, maintaining the drain in a productive state, without the surrounding tissues continually occluding the drainage holes in the tube. Sump drains are often used when large fluid volumes have to be evacuated. The occlusion of the smaller venting tube by tissue debris due to retrograde inflow demonstrates a potential disadvantage of sump drains that occurs especially when the suction is disconnected. Some sump drains have an additional third lumen that allows the instillation of an irrigating solution. Collapsible devices connected to the drain tubes automatically generate a negative pressure gradient and keep the system “sealed,” which is believed to result in a significant reduction in retrograde infections.

Specific examples of drains and operations where they are commonly used include:

Plastic surgery including myocutaneous flap surgery. Breast surgery (to prevent collection of blood and lymph). Chest surgery (with, for example, the associated risks of raised intrathoracic pressure and tamponade). Infected cysts or abscesses (to drain pus). Pancreatic surgery (to drain secretions). Biliary surgery. Thyroid surgery (concern over haematoma and haemorrhage around the airway). Neurosurgery (where there is a risk of raised intracranial pressure).

Another proposed function of prophylactic drainage is the early detection of anastomotic leakage. If drains are to be used near a high-risk anastomosis, it is important that they are not placed in direct contact with the anastomosis, but, rather, with a safety margin in between to prevent drain-related erosions. This principle is illustrated for a biliodigestive anastomosis, where the drain is placed posterior to the anastomosis. Although the routine use of prophylactic drainage has often been considered as a method to prevent complications, there is growing evidence that this practice may be associated with adverse effects. Retrograde drain infections or drain-related complications are known adverse effects.

Treatment of abdominal abscesses underwent a revolutionary change during the 1990s owing to the demonstrated efficacy of percutaneous drainage by interventional radiologists . In the case of most abdominal abscesses, a skilled radiologist can find a safe route along which to insert a drainage catheter that evacuates the pus with no need to perform laparotomy or laparoscopy for drainage. This technology is especially welcome in critically ill patients who may not tolerate a major operation.

The majority of postoperative collections in the upper abdomen are manageable by means of percutaneous drainage by interventional radiologic techniques using standard aseptic technique and local anesthesia. In this way, collections are drained percutaneously under ultrasonographic or CT guidance using the Seldinger or trocar techniques. Some fluid collections may require surgical drainage with repeated abdominal lavage and second-look procedures.

Many gastrointestinal operations can be performed safely without prophylactic drainage . Drains should be omitted after hepatic, colonic or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis.

A retrospective review found that even the complicated appendicitis (with secondary peritonitis and sepsis) in the modern era of antibiotics does not necessitate the use of prophylactic drain placement which, at times, may even prove counterproductive.

Prophylactic drainage is recommended after esophageal resection and total gastrectomy. For many other gastrointestinal procedures (especially involving the upper gastrointestinal tract) there is a need for more research to clarify the value of prophylactic drainage.

There is insufficient evidence showing that routine drainage after colorectal anastomosis prevents anastomotic and other complications . Damage may be caused by mechanical pressure or suction and drains may even induce an anastomotic leak. Drains are not a substitute for good surgical technique.