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by 
Dr.Imran Sadiq 
King Abdul Aziz Naval Base Hospital
 First recorded use of drains is attributed to 
Hippocrates (460-377 BC ) for Empyema 
 Lorenz Heister of Numberg (1683-1758 ) 
introduce the principle of capillary (action) 
drainage . 
 Eugene Koeberle of Strasbourg(1865) used a 
glass tube drain .
 Heaton ( 1889 ) is credited with introducing 
suction drainage . 
 Murphy ( 1947 ) introduced a technique for 
intermittent suction . 
 Closed-system , continuous suction 
introduced by Baron (1950 ) .
1. Active Drains 
 Closed 
JP(Jackson-Pratt Drain), 
Redivac Suction Drain 
 Open 
Sump Drain 
FLUID 
AIR
1. Passive Drains 
 Closed 
NGT, Foleys catheter, 
T-Tube, Nelaton Drain etc. 
 Open 
Penrose drains, 
corrugated Drains
Active Drain Passive Drain 
Function Works by negative 
pressure created by 
compressible drums or 
mechanical evacuation 
system 
Depends upon 
pressure differentials 
& gravity 
Pressure Gradient Negative Pressure Normal 
Drain Exit site Dependent Position is 
not necessary 
Dependent position 
for best function 
Retrograde Infection Lower incidence Higher incidence 
Fluid collection Decreased incidence 
because negative 
pressure improves 
tissue apposition & 
obliterates dead space 
Increased incidence 
because of limited 
effect on dead space 
Obstruction of Drain More common Less common 
Pressure necrosis Greater incidence Less common
 In 1905 Yates claimed “ drainage of General 
Peritoneal cavity is physically and 
physiologically impossible”. 
 Gravitz’s stated “ Peritoneum is able to 
reabsorb secretions and combat bacteria.”
Review of 
literature/Research work. 
This is the most sophisticated way to get benefit 
from the work and experiences of others in this era.
 1992 
 “the conscientious,explicit,judicious use of 
current best evidence in making decisions 
about the care of individual patients.” 
( conscientious -------- attentive, Luborious,Pain taking) 
( Explicit------------------ Obvious) 
( Judicious--------------- Logical,Rational)
Its basic principles are that all practical 
decisions made should 
 Be based on Research studies. 
 That the Research studies are selected and 
interpreted according to some specific norms 
characteristic for EBP. 
 The results should be analyzed and compared 
with standards.
 How to Review the literature/Research work? 
 Which Research work is Reliable and 
practicable?
 Anything present in support of an assertion 
(statement). 
 Evidence is comprised of research findings 
delivered from the systemic collection of Data 
through observation & experiment and the 
formulation of Question & testing of 
Hypothesis. 
 There are certain scales to measure Evidence 
(levels of Evidence ) 
 Recommendations are made by different 
Research Groups.
Uses of drain in abdominal surgery
Grading of Recommendations Assessment, Development 
and Evaluation (GRADE) 
•Source: GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007(modified by EBM guideline editorial team) 
Code 
Quality of 
Evidence 
Definition 
A High 
Further research is very unlikely to change 
our confidence in the estimate of effect. 
•Several high-quality studies with consistent 
results 
•In special cases: one large, high-quality 
multi-centre trial 
B Moderate 
Further research is likely to have an 
important impact on our confidence in the 
estimate of effect and may change the 
estimate. 
•One high-quality study 
•Several studies with some limitations 
C Low 
Further research is very likely to have an 
important impact on our confidence in the 
estimate of effect and is likely to change the 
estimate. 
•One or more studies with severe limitations 
D Very Low 
Any estimate of effect is very uncertain. 
•Expert opinion 
No direct research evidence
University of Michigan Practice Guideline: 
A: Randomized controlled trials. 
B: 
Controlled trials, no 
randomization. 
C: Observational trials. 
D: Opinion of the expert panel
 Cochrane collaboration: A worldwide 
association of groups who create and 
maintain systematic reviews of the literature 
for specific topic areas. 
Cochrane Review 
 USPSTF ( US Preventive Services Task Force) 
 AHRQ ( Agency of Health Care Research & 
Quality)
A systematic Review & Meta-Analysis 
 Source. Ann Surg. Dec,2004; 240 (246) 
 Author from Switzerland, Department of 
Visceral & Transplant Surgery, University 
Hospital.
 Review of Articles Comparing Prophylactic 
Drainage Vs No Drainage in GI Surgery from 
1966 to 2004. 
 17 RCTs for Hepato-pancreatico-biliary 
Surgery. 
 None for upper GI Tract 
 13 for Lower GI Tract.
 All studies were classified according to their 
level of Evidence and then graded (A,B,C,D) as 
suggested by Oxford Centre for EBM. 
 Studies were compared for the following end 
points: mortality, overall complication rates, 
leakage rates, infection rates (wound, intra-abdominal 
collections, abscess), pulmonary 
complication rates, reoperation rates, and 
hospital stay.
 Open Cholecystectomy numerous RCTs and 
Meta-analysis by Lewis et al, failed to 
demonstrate a reduction of post-operative 
complications by routine drainage. (Level 1a) 
 Lap. Cholecystectomy 2 RCTs, 4 of 34 (11.7%) 
of drained had complications while in non 
drained 2 of 33 (6.1%) had 
complications.(Level 1a)
 No RCT prospective study 
 One non Randomized Prospective Cohort 
study (level 2b) 
 “The role of Prophylactic Drains after Surgery 
for Perforated Duodenal Ulcer.”
 Total pts. 119 
 Omental Patch Technique 
 75 pts. With Drain 
 44 pts. Without drain
 Drainage neither reduced the incidence of 
intra abdominal fluid collection including 
abscess formation nor the duration of 
Hospital stay. 
 But there were a significant number of Drain 
related complications such as 
Drain Tract infection (10.7%) 
Acute Intestinal obstruction (2.7%)
 Meta analysis 
 8 RCTs on Abdominal/Pelvic Drainage vs no 
Drainage 
 3 RCTs has Level 1b 
 5 RCTs has Level 2b 
 717 pts. with Drain 
 673 pts. without Drain 
 Majority of studies on Elective Surgery 
 2 studies include Emergency cases
 A slight advantage for non drained patients 
in respect to clinical leakage (OR 1.38; CI 
0.77–2.49) and wound infections (OR 1.41; CI 
0.87–2.29) was documented, although this 
advantage was not statistically significant. 
 Moreover, the meta-analysis by Urbach et al 
showed that in only 1 of 20 clinical leakages 
pus or feces emerged through the 
drain,indicating that drains have a low 
sensitivity (5%) to detect clinical leakage.
Uses of drain in abdominal surgery
 Open Appendectomy 
 Five RCTs on prophylactic drainage for 
gangrenous and perforated appendicitis were 
identified (level of evidence 2b). 
 The results showed higher wound infection rates 
in drained patients (range 43–85%) than in non 
drained patients (range 29–54%). 
 The pattern of intra-abdominal infections was 
not uniform among the studies, as 2 studies 
reported slightly higher intra-abdominal 
infection rates in non drained patients,1 study a 
higher rate in drained .
 Meta-analysis including series with gangrenous 
or perforated appendicitis only. 
 Four RCTs (all level 2b) were included in the 
meta-analysis with the end point wound 
infection, whereas data from 3 RCTs were 
available for the end points intra-abdominal 
infection and fecal fistula . 
 The analysis calculated an OR for wound 
infections of 1.75 (CI 0.96–3.19). The OR for 
fecal fistulas of 12.4 (CI 1.14–135) favors the no-drainage 
group, whereas the OR for the end point 
intra-abdominal infection of 1.43 (CI 0.39–5.29) 
favors neither group.
Cochrane Review 
Published on 3rd Sep. 2013 
 12 RCTs 
 1831 participants 
 915 pts with drain 
 916 pts without drain 
 9 RCTs include elective cholecystectomies 
 1 RCT include Acute cholecystitis 
 2 RCTs include both elective & emergency 
cholecystectomies
 There was no significant or clinically 
important differences in the short-term 
mortality, serious complications, quality of 
life, length of hospital stay, operating time, 
return to normal activity, or return to work in 
the trials that reported these outcomes. 
 The proportion of patients who were 
discharged as day-procedure laparoscopic 
cholecystectomy seemed significantly lower 
in the drain group than in the 'no drain' group 
.
Journal of Minimal Access Surgery; 2012,Jul- 
Sep 
Suez Canal Hospital 
 RCT (Prospective) 
 Single Blind (Team Accessing Results) 
 Level of Evidence 1b 
 Group A with Drain ( closed Passive Drain) 
 Group B without Drain 
 Assessment. Post op Pain ,wound infection 
& Hospital stay
 Post op Pain VAS no difference at 24,48hrs & 
1week. 
 Hospital Stay 
Group A 1--3 days 
Group B 1-- 2days
East & Centeral African Journal of Surgery 
Vol.16,No 2,Jul/Aug 2011;62-71 
 Prospective RCT 
 90 pts. 
 Pts with generalized Peritonitis were excluded 
 45 pts. With drain (closed without suction) 
 45 pts. Without drain
Other complications included fecal fistula (2patients), 
intraperitoneal abscess (3 patients) and paralytic ileus 
(1 patient) all of them occurring in patients with 
drains.
 Many GI operations can be performed safely 
without prophylactic drainage. Drains should 
be omitted after colonic, or rectal resection 
with primary anastomosis and appendectomy 
for any stage of appendicitis 
(recommendation grade A). 
 Currently, there is no evidence to support the 
use of drain after laparoscopic 
cholecystectomy (recommendation grade A). 
Further well-designed randomised clinical 
trials are required.
In any surgical procedure, good hemostasis, 
appropriate antibiotics use and precise 
surgical 
technique with minimal tissue trauma limit 
the need 
for operative drain placement.
Uses of drain in abdominal surgery

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Uses of drain in abdominal surgery

  • 1. by Dr.Imran Sadiq King Abdul Aziz Naval Base Hospital
  • 2.  First recorded use of drains is attributed to Hippocrates (460-377 BC ) for Empyema  Lorenz Heister of Numberg (1683-1758 ) introduce the principle of capillary (action) drainage .  Eugene Koeberle of Strasbourg(1865) used a glass tube drain .
  • 3.  Heaton ( 1889 ) is credited with introducing suction drainage .  Murphy ( 1947 ) introduced a technique for intermittent suction .  Closed-system , continuous suction introduced by Baron (1950 ) .
  • 4. 1. Active Drains  Closed JP(Jackson-Pratt Drain), Redivac Suction Drain  Open Sump Drain FLUID AIR
  • 5. 1. Passive Drains  Closed NGT, Foleys catheter, T-Tube, Nelaton Drain etc.  Open Penrose drains, corrugated Drains
  • 6. Active Drain Passive Drain Function Works by negative pressure created by compressible drums or mechanical evacuation system Depends upon pressure differentials & gravity Pressure Gradient Negative Pressure Normal Drain Exit site Dependent Position is not necessary Dependent position for best function Retrograde Infection Lower incidence Higher incidence Fluid collection Decreased incidence because negative pressure improves tissue apposition & obliterates dead space Increased incidence because of limited effect on dead space Obstruction of Drain More common Less common Pressure necrosis Greater incidence Less common
  • 7.  In 1905 Yates claimed “ drainage of General Peritoneal cavity is physically and physiologically impossible”.  Gravitz’s stated “ Peritoneum is able to reabsorb secretions and combat bacteria.”
  • 8. Review of literature/Research work. This is the most sophisticated way to get benefit from the work and experiences of others in this era.
  • 9.  1992  “the conscientious,explicit,judicious use of current best evidence in making decisions about the care of individual patients.” ( conscientious -------- attentive, Luborious,Pain taking) ( Explicit------------------ Obvious) ( Judicious--------------- Logical,Rational)
  • 10. Its basic principles are that all practical decisions made should  Be based on Research studies.  That the Research studies are selected and interpreted according to some specific norms characteristic for EBP.  The results should be analyzed and compared with standards.
  • 11.  How to Review the literature/Research work?  Which Research work is Reliable and practicable?
  • 12.  Anything present in support of an assertion (statement).  Evidence is comprised of research findings delivered from the systemic collection of Data through observation & experiment and the formulation of Question & testing of Hypothesis.  There are certain scales to measure Evidence (levels of Evidence )  Recommendations are made by different Research Groups.
  • 14. Grading of Recommendations Assessment, Development and Evaluation (GRADE) •Source: GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007(modified by EBM guideline editorial team) Code Quality of Evidence Definition A High Further research is very unlikely to change our confidence in the estimate of effect. •Several high-quality studies with consistent results •In special cases: one large, high-quality multi-centre trial B Moderate Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. •One high-quality study •Several studies with some limitations C Low Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. •One or more studies with severe limitations D Very Low Any estimate of effect is very uncertain. •Expert opinion No direct research evidence
  • 15. University of Michigan Practice Guideline: A: Randomized controlled trials. B: Controlled trials, no randomization. C: Observational trials. D: Opinion of the expert panel
  • 16.  Cochrane collaboration: A worldwide association of groups who create and maintain systematic reviews of the literature for specific topic areas. Cochrane Review  USPSTF ( US Preventive Services Task Force)  AHRQ ( Agency of Health Care Research & Quality)
  • 17. A systematic Review & Meta-Analysis  Source. Ann Surg. Dec,2004; 240 (246)  Author from Switzerland, Department of Visceral & Transplant Surgery, University Hospital.
  • 18.  Review of Articles Comparing Prophylactic Drainage Vs No Drainage in GI Surgery from 1966 to 2004.  17 RCTs for Hepato-pancreatico-biliary Surgery.  None for upper GI Tract  13 for Lower GI Tract.
  • 19.  All studies were classified according to their level of Evidence and then graded (A,B,C,D) as suggested by Oxford Centre for EBM.  Studies were compared for the following end points: mortality, overall complication rates, leakage rates, infection rates (wound, intra-abdominal collections, abscess), pulmonary complication rates, reoperation rates, and hospital stay.
  • 20.  Open Cholecystectomy numerous RCTs and Meta-analysis by Lewis et al, failed to demonstrate a reduction of post-operative complications by routine drainage. (Level 1a)  Lap. Cholecystectomy 2 RCTs, 4 of 34 (11.7%) of drained had complications while in non drained 2 of 33 (6.1%) had complications.(Level 1a)
  • 21.  No RCT prospective study  One non Randomized Prospective Cohort study (level 2b)  “The role of Prophylactic Drains after Surgery for Perforated Duodenal Ulcer.”
  • 22.  Total pts. 119  Omental Patch Technique  75 pts. With Drain  44 pts. Without drain
  • 23.  Drainage neither reduced the incidence of intra abdominal fluid collection including abscess formation nor the duration of Hospital stay.  But there were a significant number of Drain related complications such as Drain Tract infection (10.7%) Acute Intestinal obstruction (2.7%)
  • 24.  Meta analysis  8 RCTs on Abdominal/Pelvic Drainage vs no Drainage  3 RCTs has Level 1b  5 RCTs has Level 2b  717 pts. with Drain  673 pts. without Drain  Majority of studies on Elective Surgery  2 studies include Emergency cases
  • 25.  A slight advantage for non drained patients in respect to clinical leakage (OR 1.38; CI 0.77–2.49) and wound infections (OR 1.41; CI 0.87–2.29) was documented, although this advantage was not statistically significant.  Moreover, the meta-analysis by Urbach et al showed that in only 1 of 20 clinical leakages pus or feces emerged through the drain,indicating that drains have a low sensitivity (5%) to detect clinical leakage.
  • 27.  Open Appendectomy  Five RCTs on prophylactic drainage for gangrenous and perforated appendicitis were identified (level of evidence 2b).  The results showed higher wound infection rates in drained patients (range 43–85%) than in non drained patients (range 29–54%).  The pattern of intra-abdominal infections was not uniform among the studies, as 2 studies reported slightly higher intra-abdominal infection rates in non drained patients,1 study a higher rate in drained .
  • 28.  Meta-analysis including series with gangrenous or perforated appendicitis only.  Four RCTs (all level 2b) were included in the meta-analysis with the end point wound infection, whereas data from 3 RCTs were available for the end points intra-abdominal infection and fecal fistula .  The analysis calculated an OR for wound infections of 1.75 (CI 0.96–3.19). The OR for fecal fistulas of 12.4 (CI 1.14–135) favors the no-drainage group, whereas the OR for the end point intra-abdominal infection of 1.43 (CI 0.39–5.29) favors neither group.
  • 29. Cochrane Review Published on 3rd Sep. 2013  12 RCTs  1831 participants  915 pts with drain  916 pts without drain  9 RCTs include elective cholecystectomies  1 RCT include Acute cholecystitis  2 RCTs include both elective & emergency cholecystectomies
  • 30.  There was no significant or clinically important differences in the short-term mortality, serious complications, quality of life, length of hospital stay, operating time, return to normal activity, or return to work in the trials that reported these outcomes.  The proportion of patients who were discharged as day-procedure laparoscopic cholecystectomy seemed significantly lower in the drain group than in the 'no drain' group .
  • 31. Journal of Minimal Access Surgery; 2012,Jul- Sep Suez Canal Hospital  RCT (Prospective)  Single Blind (Team Accessing Results)  Level of Evidence 1b  Group A with Drain ( closed Passive Drain)  Group B without Drain  Assessment. Post op Pain ,wound infection & Hospital stay
  • 32.  Post op Pain VAS no difference at 24,48hrs & 1week.  Hospital Stay Group A 1--3 days Group B 1-- 2days
  • 33. East & Centeral African Journal of Surgery Vol.16,No 2,Jul/Aug 2011;62-71  Prospective RCT  90 pts.  Pts with generalized Peritonitis were excluded  45 pts. With drain (closed without suction)  45 pts. Without drain
  • 34. Other complications included fecal fistula (2patients), intraperitoneal abscess (3 patients) and paralytic ileus (1 patient) all of them occurring in patients with drains.
  • 35.  Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A).  Currently, there is no evidence to support the use of drain after laparoscopic cholecystectomy (recommendation grade A). Further well-designed randomised clinical trials are required.
  • 36. In any surgical procedure, good hemostasis, appropriate antibiotics use and precise surgical technique with minimal tissue trauma limit the need for operative drain placement.