Prophylactic Drainage

Drain Orifice

The drain orifice through the skin is created by a penetrating cut with a scalpel (A-1). A Kelly clamp is inserted into the orifice (A-2) and penetrates the abdominal wall diagonally (A-3). The hand serves as protection to prevent bowel injury. This technique creates a tunnel that helps to seal the abdominal cavity after drain removal. After clamping the drain tip, the Kelly clamp and drain are pulled through the abdominal wall from inside outwards (A-4). Others prefer to create the tunnel from inside out and pull the drain into the abdomen. Finally, the drain position is secured by a non-reactive skin suture, and the drain tube is connected to the suction device.

Prophylactic Drains

Prophylactic drainage after upper abdominal operations is used to evacuate intraabdominal fluid that may develop, such as ascites, blood, chyle, bile, pancreatic, or intestinal juice, that are either harmful/toxic for adjacent tissue or might become infected. Therefore, drains are placed in spaces that tend to accumulate fluid, such as the subhepatic (1), right subphrenic (2), left subphrenic (3), and parapancreatic (4) spaces.

Biliodigestive Anastomose Pancreas

Anastomosis Drains

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. Several randomized, controlled trials are available investigating the routine use of prophylactic drainage (Table2).

Table2. Evidence-based recommendations for prophylactic drainage practice

Gastrointestinal surgery

Procedures

Evidence-based recommendation

Hepatic resection without

No drain

biliodigestivg anastomosis

Cholecystectomy (open, laparoscopic)

No drain

Pancreatic rcsection

No drain8

Biliodigestive anasLomosis

NA

Esophageal resections

Intrathoracic drain

for any approach

Total gastrectomy

Drain

Distal gastrectomy

No drain

Roux-en-Y gastric bypass

NA

Duodenotomy with omental

No drain

patch for duodenal perforation

Hep ato - pancreaticobiliary

Upper GI tract

NA not assessed aOnly one randomized controlled trial in pancreatic cancer

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