Placement Of Drainage Tubes During Abdominal Surgery

Drainage mechanism of peritoneal drainage tubes

The peritoneal fluid is passively drained into the drainage bag through the peritoneal drainage tube mainly by siphoning. Its mechanism of action is that the fluid in the cavity at a higher position in the body flows into the drainage bag at a lower position through the drainage tube; the condition is that the pressure in the body cavity is equal to the pressure in the drainage bag, and the tube opening in the drainage tube cannot be exposed to the liquid surface.

Types of peritoneal drainage tubes

According to the purpose of placing peritoneal drainage tubes, they can be divided into therapeutic and preventive drainage tubes.

Therapeutic drainage tubes:

* Infectious diseases such as liver abscess, abdominal/pelvic abscess;

* Biliary drainage tubes placed during hepatobiliary disease surgery, such as temporary or permanent external bile drainage tubes placed for obstructive jaundice;

* T-tubes placed for cholelithiasis or biliary stenosis;

* Gastroenterostomy tubes for enteral nutrition after gastrointestinal surgery, etc.

Preventive drainage tubes:

* Drainage tubes placed in the abdominal cavity, pelvic cavity or subdiaphragmatic cavity after major abdominal surgery such as radical gastrectomy, colorectal cancer radical resection, liver resection and pancreaticoduodenectomy, and drainage tubes placed after severe abdominal trauma and infection. The purpose is to prevent abdominal effusion and reduce the occurrence of abdominal infection. At the same time, postoperative complications such as active bleeding, intestinal fistula, bile fistula, abdominal infection, etc. can be detected early to facilitate early treatment.

Indications for abdominal drainage

Therapeutic drainage:

*Localized abscesses, pathological effusions, etc.;

*Gastrointestinal fistulas;

*To relieve tension and compression, such as accumulation of gas or fluid or tissue edema, etc.

Preventive drainage:

*When secondary infection, bleeding, gastrointestinal fistulas, effusions, gas accumulation, etc. are likely to occur despite surgical treatment

Precautions for abdominal drainage

(1) Determine the drainage method and drainage material based on the nature of the disease and the situation during surgery. When intestinal preparation cannot be performed before surgery, when the tissues sutured or anastomosed during gastrointestinal surgery have obvious inflammation, scars, edema or ischemia, and it is difficult to prevent fistulas, and when necrotic tissue cannot be completely removed after traumatic surgery, drainage should be placed, generally in the form of closed suction. Adequate drainage must be performed during surgery for acute necrotizing pancreatitis, both for treatment and to prevent further pancreatic necrosis.

(2) Generally, the inner end of the drainage tube should be placed at the bottom of the wound or close to the area that needs drainage. In gastrointestinal surgery, it should be placed near the anastomosis, otherwise the drainage will be insufficient and dead space will remain.

(3) The drainage tube is generally not taken out from the original incision, but is led out from the body surface through another hole next to the incision to avoid contaminating the entire incision and causing infection.

(4) The drainage tube must be firmly fixed to prevent it from slipping out of the incision or falling into the body. Generally, the drainage tube is fixed to the skin with sutures.

(5) When suturing the tissue, be careful not to sew the drainage tube into the deep tissue, otherwise it will be difficult to remove the drainage tube smoothly.

(6) After surgery, the drainage must be maintained unobstructed and the obstruction in the drainage tube must be cleared immediately.

(7) After surgery, the amount, color, and odor of the drainage fluid should be carefully observed to determine the outcome of the disease.

Indications for drainage tube removal

The time for drainage tube removal is generally determined according to different drainage indications and drainage volume. If the tube is removed too early, the secretions will not be fully drained and will accumulate again. If it is removed too late, the chance of infection will increase, affecting wound healing and even causing other complications.

(1) Drainage of blood in the body cavity during sterile surgery

In general, in the body cavity, if the exudate (blood) has stopped or the drainage volume is less than 30~50ml/d, the preventive drainage material can be removed once within 24~48 hours after surgery. When removing it, it should be rotated and loosened first to separate the adhesion of the drainage tube from the surrounding tissue, and then removed outward. If there is an obstacle, do not pull it hard to avoid breaking it. You can wait until the next day to remove it. Pay more attention to the fixed drainage material inside. If there are several drainage tubes, they can be removed in batches.

(2) Abscess drainage

When the abscess cavity is reduced and the drainage volume is significantly reduced to less than 10ml/d, you can replace the thin drainage tube or remove it gradually to fill the wound with granulation tissue to prevent the skin layer from healing prematurely. Sometimes, X-ray angiography or ultrasound, CT or MRI can be used to observe whether the abscess cavity disappears, and then decide whether the drainage tube can be removed.

(3) Gastroduodenal decompression tube

It is usually removed 2 to 5 days after surgery. The indications for removal are: ① The suction volume is reduced, there is no obvious abdominal distension, and there is no abdominal distension after clamping the tube. ② Intestinal peristalsis is restored, and bowel sounds are normal. ③ There is gas discharge or defecation from the anus.

(4) Common bile duct drainage tube

It is usually removed 2 to 3 weeks after surgery. Two points should be made clear when removing it: ① There is no infection in the bile duct, and ② The distal end of the common bile duct is unobstructed. The indications for removal are:

Normal body temperature, jaundice subsided, clear bile, no flocs and stone residues, and no pus balls under microscopic examination.

The bile drainage volume decreases day by day, and the stool color is normal.

The drainage tube is raised and clamped for three days, without distension and discomfort in the right upper abdomen, and no fever or jaundice.

Cholangiography: 20-60 ml of 12.5% sodium iodide solution is injected through the drainage tube. X-ray examination proves that there is no obstruction at the lower end of the common bile duct and no stones exist. Or B-ultrasound examination shows that the T-tube choledochoscopy is normal. After the tube is removed, the wound is covered with vaseline gauze and the dressing is changed. It will heal in about a week. If the operation is limited to common bile duct exploration or stone removal, the drainage tube can be removed about 10 days after the operation. If the bile duct infection is severe or there are residual stones in the hepatobiliary duct, the drainage time should be extended, and the stones can be removed through the drainage tube choledochoscopy. The drainage support tube after the repair of bile duct stenosis or injury should be retained for several weeks to several months. If a second operation is required, the drainage tube should not be removed so that the common bile duct can be found during the operation.

(5) Chest drainage tube

The closed chest drainage tube must be firmly connected to the water seal bottle to avoid the joint falling off and air inhaled into the chest cavity causing acute pneumothorax.

The end of the water-sealed bottle glass drainage tube should be placed 2~3cm below the horizontal plane, and the depth of the glass tube into the water should be adjusted according to the amount of drainage. The water-sealed bottle should be 15cm below the patient's chest to facilitate drainage. Suction devices should be used for those with large drainage volume. The effective negative pressure suction of the chest tube is 15~20cmH2O.

Indications for extubation: Depends on the condition, generally removed 2~4 days after surgery. ① The lungs are well inflated (determined by lung auscultation and X-ray examination). ② There is no fluctuation in the water column of the water-sealed bottle glass tube or the drainage volume is less than 50~60ml within 24 hours. ③ Clamp the tube for 24 hours, and the chest cavity no longer accumulates air, then the tube can be extubated.

Method of extubation: First cut off the sutures that fix the drainage tube, ask the patient to take a deep breath and hold his breath, and pull out the tube at the same time. Immediately cover the wound with vaseline gauze and thick dressings, fix it to the chest wall with tape, and keep it for 12~24 hours to prevent air from being inhaled into the chest cavity.

When the drainage tube of empyema is closed, water should be injected frequently to measure the size of the abscess cavity. If necessary, iodized oil or 12.5% sodium iodide solution should be injected into the abscess cavity for contrast imaging. If the abscess cavity is reduced to <15ml, the drainage tube can be removed, the wound dressing can be changed, and it can heal on its own. If it is open drainage, its treatment is the same as the general abscess cavity drainage principle.

Drainage after several common general surgery operations

(1) Drainage of gastrointestinal surgery

Peritoneal drainage has a long history as a model of surgical drainage. With the accumulation of experience, it is found that peritoneal drainage also brings certain complications, and draining the entire abdominal cavity is physically and biologically impossible and unnecessary. Because the absorption capacity of the abdominal cavity is quite strong, it can absorb peritoneal exudate and kill bacteria.

For general upper gastrointestinal surgery, as long as aseptic operation is paid attention to during the operation, there is no need to place preventive peritoneal drainage after the operation. Preventive drainage should be retained until 7 to 10 days after the operation or 1 to 2 days after the patient eats, otherwise it is of little significance. After partial resection of the small intestine and intestinal anastomosis, it is generally not necessary to place a drainage tube.

After appendectomy, regardless of the degree of inflammation of the appendix, it is not recommended to place a drainage tube. Although there is still controversy about whether to place a drainage tube after appendectomy perforation peritonitis, the only clear indication for drainage after appendectomy is when the abscess around the appendix needs to be incised and drained.

Once stump leakage and anastomotic leakage occur after gastrointestinal surgery, gastrointestinal contents flow into the abdominal cavity, causing peritonitis, followed by abdominal infection and even abdominal abscess formation. Therefore, adequate drainage is the most basic method to deal with stump leakage or anastomotic leakage.

(2) Drainage after liver surgery

After liver surgery, drainage is only used as a preventive measure or as an indicator to observe whether there is secondary bleeding and effusion in the body. Proper drainage can prevent the accumulation of blood, effusion, bile or other fluids in the body, thereby preventing the occurrence of postoperative infection. Silicone tube drainage should be placed routinely, and attention should be paid to observing the blood, bile, and ascites.

The drainage tube generally needs to be placed for 2 to 3 days, but attention should be paid to the quality and quantity of the drainage. If there is blood, exudate or drainage volume ≥50~100ml/24 hours, the time of extubation should be extended. For patients with cirrhosis, the time of extubation should be appropriately extended, and liver protection treatment should be done well.

For the drainage of liver abscesses, the size, number and location of the abscess should be understood as much as possible through B-ultrasound, CT and other examinations before surgery. Non-surgical puncture 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, the abscess wall often cannot collapse and heal on its own in a short period of time after the abscess is emptied. The drainage should not be removed prematurely. If necessary, it should be combined with the application of antibiotic solution irrigation. After the abscess cavity is filled with granulation tissue, the drainage should be gradually removed.

(3) Drainage of biliary diseases

Drainage is very important in biliary surgery. The selection of appropriate drainage can improve the efficacy and reduce the occurrence of complications. In some cases, it can replace surgery.

After cholecystectomy for gallbladder gangrene and gallbladder perforation, although the primary lesion has been removed, there must be inflammatory exudation around the gallbladder. Timely drainage can prevent accumulation and avoid abscess formation. Cigarettes and porous silicone tubes are often used for drainage. If there is not much exudation, it can be removed.

After conventional cholecystectomy, a thicker tube should be used to observe bleeding. If there is no bleeding within 24 hours after surgery, it should be removed as soon as possible. To prevent bile leakage, a porous silicone tube should be used, and it can be removed after 1 to 2 days without bile leakage.

After bile duct incision and cholechojejunostomy, preventive drainage can be removed after the incision and anastomosis heal for about a week. If bile leakage occurs after surgery, drainage should be continued until the fistula heals.

For patients with gallbladder duct obstruction and poor overall health who cannot tolerate cholecystectomy, or with a long attack time and severe inflammation of the gallbladder triangle, the local anatomy is difficult to identify. Cholecystotomy and drainage (fistula) are performed to relieve gallbladder high pressure, which can relieve symptoms, avoid gallbladder gangrene and perforation, and control inflammation. Radical cholecystectomy should be performed after the condition improves.

A mushroom-shaped tube is used for cholecystostomy, and drainage generally continues until the second-stage surgical cholecystectomy. There are many methods for bile duct drainage, including surgical incision of the bile duct and insertion of a T-tube for drainage, percutaneous transhepatic puncture, and endoscopic insertion of a nasobiliary drainage tube. Drainage should be continued until jaundice subsides or symptoms do not worsen after clamping the tube, but the tube must be placed for more than 14 days.

T, Y and long-arm T tubes are commonly used for drainage to support the bile duct to prevent stenosis. They are generally placed for 6 months or more.

(4) Drainage of the pancreas

After pancreatic tumor surgery, the main focus is on preventing postoperative pancreatic fluid leakage. The preparation, placement and placement time of the drainage material must take into account that in case of pancreatic fluid leakage, there is an effective active suction drainage to stop it at the beginning stage.

After surgery for severe pancreatitis, the main focus is on making up for the shortcomings of the surgery. Active drainage should be used, plus continuous irrigation, and the drainage lumen should be large enough to ensure that small sloughed necrotic tissue can be discharged.

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