The placement of abdominal drains after abdominal surgery is an important tool to prevent postoperative complications and treat some surgical disorders, but it is also a controversial technique. On the one hand, the placement of abdominal drains is beneficial to the drainage or discharge of fluid accumulated in the abdominal cavity (including blood, pus, inflammatory exudate, bile, secretion, etc.); but on the other hand, abdominal drains also aggravate the chances of gastrointestinal fistula, intestinal adhesions, abdominal infections, etc.
I. Mechanism of action of abdominal drainage tube drainage
Intra-abdominal fluid mainly relies on the siphoning effect through the abdominal drainage tube passive drainage to the drainage bag, its mechanism of action is: the body position of higher intracavitary fluid through the drainage tube into the lower position of the drainage bag. The condition is that the pressure in the body cavity is equal to the pressure in the drainage bag, and the mouth of the drainage tube cannot be exposed to the liquid surface.
Second, the type of abdominal drainage
According to the purpose of placing abdominal drainage tube can be divided into therapeutic and prophylactic drainage tube.
1, therapeutic drains: a infectious diseases: such as liver abscess, abdominal/pelvic abscess; b biliary drains placed for surgery for hepatobiliary diseases: temporary or permanent external biliary drains placed for obstructive jaundice; T-tubes placed for gallstone disease or biliary strictures; c gastrointestinal stoma tubes for enteral nutrition after gastrointestinal surgery, etc.
2.Prophylactic drainage tube: abdominal major surgery such as radical surgery for gastric cancer, radical surgery for colorectal cancer, hepatectomy and pancreaticoduodenectomy etc. placed in the abdominal cavity, pelvic cavity or subdiaphragmatic drainage after surgery, and drainage tube placed after serious abdominal trauma and infection. The purpose is to prevent the accumulation of fluid in the abdominal cavity and reduce the occurrence of abdominal infection, and to facilitate the early detection of postoperative complications such as active bleeding, intestinal fistula, biliary fistula, abdominal infection, etc. for early treatment.
Third, the indications for abdominal drainage
Therapeutic drainage: a limited abscess, pathological effusion, etc.; b gastrointestinal fistula; c in order to reduce tension compression, such as accumulation of gas, fluid or tissue edema, etc.
Prophylactic drainage: it is applied when it is easy to secondary infection, bleeding, gastrointestinal fistula, fluid accumulation, gas accumulation, etc. despite surgical treatment.
Fourth, the abdominal drainage precautions
1, according to the nature of the disease, the situation during surgery to decide what drainage method and what drainage material to choose. When the intestinal tract is not prepared before surgery, when there is obvious inflammation, scarring, edema or ischemia in the tissues sutured or anastomosed for gastrointestinal surgery, when it is difficult to prevent fistula, when necrotic tissue is not completely removed after trauma surgery, drainage should be placed, and generally closed suction is appropriate. Acute necrotizing pancreatitis surgery must be adequately drained, both for treatment and to prevent further necrosis of the pancreas.
2. Generally, the inner end of the drainage tube should be placed at the bottom of the wound or close to the site where drainage is needed, and gastrointestinal surgery should be placed near the anastomosis. Otherwise, the drainage is not sufficient and the dead space remains.
3, the drainage tube generally does not come out of the original incision, but from the incision next to another poke hole to lead out of the body, so as not to contaminate the entire incision with infection.
4, the drainage tube must be fixed firmly to prevent the drainage tube from slipping out of the incision or falling into the body. The drainage tube is usually fixed to the skin with sutures.
5, when suturing the tissue, be careful not to sew the drainage tube in the deep tissue, otherwise it will be difficult to remove the drainage tube smoothly.
6.After the operation, the drainage must be maintained and the blockage in the drainage tube should be cleared immediately.
7. The quantity, color and odor of the drainage fluid should be observed in detail after surgery to determine the regression of the disease.
V. Indications for drainage tube removal
The time of drainage tube removal is generally decided according to different drainage indications and drainage flow. If it is pulled out too early, the secretion is not sufficiently drained and re-accumulates. If it is removed too late, the chance of infection increases, affecting wound healing and even producing other complications.
(a) Blood drainage of body cavity for aseptic surgery: In general, in the body cavity, prophylactic drains such as exudate (blood) has stopped or the drainage flow is less than 30~50ml/d, can be removed at once within 24~48 hours after surgery. The drainage tube should be rotated and loosened to separate the adhesions between the drainage tube and the surrounding tissues, and then removed outward. If there is an obstacle, do not pull hard to avoid fracture, can wait for the next day to remove, the internal fixed drains must pay more attention. If there are several drains, they can be removed in stages.
(B) Abscess drainage: In the abscess cavity shrinkage, the drainage flow is significantly reduced, less than 10ml/d, the thin drainage tube can be replaced or gradually removed, so that the wound is filled by granulation tissue to prevent premature healing of the skin layer. Sometimes, X-ray imaging or ultrasound, CT or MRI can be used to observe whether the pus cavity disappears and then decide whether the drainage tube can be removed.
(c) Drainage near the hepatic, biliary, pancreatic, duodenal, and urological surgical sutures is usually retained until 5-7 days after surgery, when all drainage fluid stops and can be removed.
(d) Gastroduodenal decompression tube: generally 2~5 days after surgery, the indications for removal of the tube are
1, the amount of suction is reduced, no obvious abdominal distension, no abdominal distension after clamping the tube.
2, intestinal peristalsis recovery, bowel sounds normal.
3, the anus has exhausted, or defecation.
(E) common bile duct drainage tube: generally removed 2 ~ 3 weeks after surgery. Two points should be clarified at the time of removal.
① no infection in the bile duct.
(ii) the distal common bile duct is clear and unobstructed. Indications for duct removal
1, normal body temperature, jaundice subsided, clear bile, no flocculent and stone residue, no pus ball on microscopic examination.
2.Bile drainage decreased day by day, normal fecal color.
3, drainage tube elevated, clamped for three days, no right upper abdominal distension and discomfort, no fever and jaundice.
4.Cholangiography: 20~60ml of 12.5% sodium iodide solution was injected from the drainage tube, and X-ray examination proved that there was no obstruction in the lower end of the common bile duct and no stone existed. Or B ultrasound examination of T-shaped duct bile duct microscopy is normal. After extubation, the wound is covered with Vaseline gauze for dressing change and will heal in about a week. If the surgery is limited to common bile duct exploration or stone extraction, the drainage tube can be removed about 10 days after surgery. If the biliary tract infection is serious or the hepatobiliary duct residual stone, the drainage time should be extended and the stone can be removed by choledochoscopy through the drainage tube. The drainage support tube should be retained for several weeks to several months after biliary stricture or injury repair. If a second surgery is needed, the drainage tube should not be removed so that the common bile duct can be searched for during surgery.
(f) Thoracic drainage tube.
1, chest closed drainage tube and water seal bottle articulation must be secure, to avoid street dislodgement, air inhalation into the chest cavity resulting in acute pneumothorax.
2, the end of the water seal bottle glass drainage tube should be placed 2 ~ 3cm below the horizontal surface, and according to the amount of drainage, adjust the depth of the glass tube into the water, the water seal bottle should be lower than the patient’s chest 15cm to facilitate drainage. The water seal bottle should be 15cm below the patient’s chest to facilitate drainage. The large amount of drainage should be attracted by the suction device. The effective negative pressure of chest tube is 15~20cmH2O.
3. Indications for extubation: depending on the condition, the tube is usually removed 2~4 days after surgery.
①Good lung expansion (determined by lung auscultation X-ray examination).
②No fluctuation in the water column of the water seal bottle glass tube or less than 50~60ml of drainage in 24 hours.
③clamped tube 24 hours, the chest cavity no longer accumulate air, you can pull out the tube.
4, extraction method: first cut the suture that fixes the drainage tube, ask the patient to inhale deeply and then hold the breath, while pulling out the tube. And immediately cover the wound with petroleum jelly gauze and thick dressing, and fix it with adhesive tape on the chest wall for 12~24 hours to prevent air inhalation into the chest cavity. 5. abscess chest drainage tube, closed drainage, to often inject water to determine the size of the pus cavity, if necessary, with iodine oil or 12.5% sodium iodide solution into the pus cavity imaging, such as pus cavity reduced to < 15ml, can remove the drainage tube, wound dressing, so that it heals on its own. If the drainage is open, the treatment is the same as the general principle of pus cavity drainage.
VI. Complications caused by abdominal drainage tube and its treatment
1, gastrointestinal fistula: often caused by direct contact of the abdominal drainage tube with the anastomosis site or suture site irritation;
2, intestinal adhesions: abdominal drainage tube is a foreign body, can stimulate the intestine and abdominal cavity and cause intestinal adhesions;
3, drainage tube fracture into the abdominal cavity: extraction must be uniform force, when encountering resistance is strictly prohibited violent tug. If the drainage tube fracture, under the guidance of ultrasound and other trial surgery or timely surgery, not blindly clip, so as not to aggravate the organ or tissue damage;
4, abdominal infection: bacteria along the abdominal drainage poke hole or abdominal drainage tube into the abdominal cavity caused by infection;
5, extraction difficulties, peritonitis after extraction: the main reasons: a fixed suture is too tight, mis-sewn drainage tube, drainage tube left for too long; b extraction pain stimulation to abdominal muscle spasm; c long distance, high negative pressure drainage so that the wall of the drainage tube and the surrounding tissue close adhesion, or intestinal fat pendulous, large omentum embedded in the lateral hole of the drainage tube, etc.. Treatment measures: do not rush to forcibly remove the tube, forcibly remove the tube may be pulled off the drainage tube stump retained in the peritoneal cavity or tear the omentum to intra-abdominal bleeding or even tear the intestinal wall, bile duct wall to diffuse peritonitis, in serious cases require reoperation;
6, other: drainage tube may also cause intra-abdominal bleeding, drainage tube mouth hernia and other rare complications.
Seven, several common post-operative drainage of general surgery
1, the drainage of gastrointestinal surgery: abdominal drainage as a model of surgical drainage has a long history. With the accumulation of experience, it was found that abdominal drainage also brings certain complications, and drainage of the entire abdominal cavity is physically and biologically impossible and unnecessary. This is because the abdominal cavity is quite absorbent and can absorb abdominal exudate and kill bacteria. It is not necessary to place prophylactic abdominal drains after general upper gastrointestinal surgery as long as intraoperative care is taken for aseptic practice. Prophylactic drainage should be kept until 7-10 days after surgery or 1-2 days after the patient has eaten, otherwise it is not very meaningful. After partial small bowel resection and intestinal anastomosis, it is generally not necessary to place drainage. After appendectomy, the placement of drainage is not advocated regardless of the degree of inflammation of the appendix. Although the placement of drains after perforated appendiceal peritonitis is controversial, the only clear indication for drainage after appendectomy is when a periappendiceal abscess requires incision and drainage. Once postoperative stump leak and anastomotic fistula occur, gastrointestinal contents can flow into the peritoneal cavity causing peritonitis, followed by abdominal infection and even abdominal abscess formation. Therefore, adequate drainage is the most basic method to deal with stump fistula or anastomotic fistula.
2, drainage after liver surgery: After liver surgery, drainage is only used as a preventive measure or as an indicator to observe the presence of secondary bleeding and fluid accumulation in the body. Proper drainage can prevent the accumulation of blood, fluid, and bile or other fluids in the body, thus preventing the occurrence of postoperative infection. A silicone tube should be routinely placed to drain the patient, and blood, bile, and ascites should be monitored. The drainage tube should be placed for 2~3 days, but the quality and quantity of drainage should be noted. If there is blood, exudate or drainage flow ≥50~100ml/24 hours, the extraction time should be extended. In the case of cirrhotic patients, the extubation time should be extended appropriately and liver preservation treatment should be done. For drainage of liver abscess, the size, quantity and location of the abscess should be understood by ultrasound and CT examination as much as possible before the operation. And non-surgical puncture and drainage can be performed under the guidance of B ultrasound and CT. For multiple abscesses the septum should be opened to facilitate thorough drainage. For thick-walled abscesses, often the pus wall cannot collapse and heal by itself in a short period of time after the abscess is emptied, so the drainage should not be removed prematurely, and if necessary, the drainage should be removed gradually with the application of antibiotic solution irrigation and after the pus cavity is filled by granulation tissue.
3, drainage of biliary tract diseases: drainage is very important in biliary surgery, the choice of appropriate drainage can improve the efficacy and reduce the occurrence of complications, and in some cases can replace surgery. After cholecystectomy for gallbladder gangrene and gallbladder perforation, although the primary lesion has been removed, but there is bound to be inflammatory exudate around the gallbladder, timely drainage can prevent accumulation and avoid abscess formation, mostly with cigarette rolls, porous silicone tube drainage, not much exudate both can be removed. After routine cholecystectomy, a thicker tube should be used to observe bleeding, and those without bleeding for 24 hours after surgery should be removed as soon as possible. For the prevention of bile leakage, a porous silicone tube is used and can be removed after 1~2 days without bile leakage. Prophylactic drainage after choledochotomy and bile-intestinal anastomosis should be removed only after the incision and anastomosis are estimated to have healed for about a week. If bile leakage occurs after surgery, continuous drainage is required until the fistula heals. In cases of cholecystic duct obstruction with poor allogenic condition that cannot tolerate cholecystectomy, or long episodes with severe inflammation of the gallbladder triangle where local anatomy is difficult to identify, cholecystotomy and drainage (fistula) is performed to relieve gallbladder hypertension, which can relieve symptoms, avoid gallbladder gangrene, perforation and control inflammation. Radical cholecystectomy will be performed when the condition improves. Cholecystostomy is performed with a bacteriovenous tube, and drainage usually continues until the second stage of surgical cholecystectomy. Bile duct drainage can be performed by surgical incision of the bile duct into a T-tube, by percutaneous transhepatic puncture, or by endoscopic placement of a nasobiliary duct. Drainage until the jaundice subsides or the symptoms do not worsen after clamping, but the placement must last more than 14 days. T, Y, and long-arm T tubes are commonly used to support bile duct drainage for stricture prevention. They are usually placed for 6 months or more.
4.Pancreatic drainage: After pancreatic tumor surgery, the main purpose is to prevent postoperative leakage of pancreatic fluid. The preparation, placement and timing of drainage should be considered in case of pancreatic fluid leakage, there is an effective active suction drainage which can stop it in the beginning stage. After surgery for severe pancreatitis, the main thing is to compensate for the fear of surgery only. Active drainage is applied, plus continuous irrigation, and the lumen of the drainage tube should be large enough to ensure that small dislodged necrotic tissue can drain.