DRAINS IN ORAL AND MAXILLOFACIAL SURGERY
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CONTENTS
Definition Purposes Principle Advantages Disadvantages Sites of drain placement Drain placement Types of drains Cotton Gauze Wicks Glove Rubber Drain www.indiandentalacademy.com Red Rubber Corrugated Drain
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Tube Drain Catheters Portex Drainage Tube Yeasts Drain Penrose Drain Cigarette Drain Shirley Drain T-Tube Sump Section Plastic Tube Drains Redivac Drain Removal of Drain www.indiandentalacademy.com
DEFINITION: It is an appliance or piece of material that acts as a channel for escape of fluid. PURPOSES: PROPHYLATIC: To prevent accumulation of fluid or blood. To encourage obliteration of dead space, otherwise accumulation of fluid acts as a separating agent and will not allow raw surfaces to collapse. THERAPEUTIC: To promote escape of fluids already accumulated. www.indiandentalacademy.com
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PRINCIPLE: The simplest and most effective method of drainage is to bring the cavity to be drained to the surface. But as it is not always possible, alternatively an artificial drain is passed down the cavity to be drained.
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ADVANTAGES: Drainage of the collected fluids removes the nidus for the infection. It monitors future development of complications like hemorrhage or leakage from suture line. It removes separating fluid from the cavity, so raw surface collapse and come in contact which will enhance rapid healing. www.indiandentalacademy.com
DISADVANTAGES: It forms a portal of entry for the bacteria. It delays the healing. It can break down suture lines. It initiates tissue reaction. It gets sealed within 6 hrs. SITE OF DRAIN PLACEMENT:
AREA
PREFERABLE DRAIN
Subcutaneous
Gauze wicks, Corrugated sheet glove drain, Soft tube drain
Subfascial
Tube drain
Intramuscular
Tube drain
Extraperitoneal
Tube drain or Corrugated sheet
Intraperitoneal
Soft drain
Cysts
Closed tube drain
Abscess
Corrugated rubber drain
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DRAIN PLACEMENT: The drain used should be Soft – not to erode surrounding tissues. Smooth – not to permit fibrin to cling to it. Preferably Radio-opaque. Of a material that will not disintegrate and leave foreign bodies in the wound. Brought out through separate stab wound and fixed properly. Non-irritant. The stab wound should be large enough to permit free drainage. Drain placed in dependent position if gravity alone is to accomplish drainage. Drain should be brought about through shortest route from abdominal wallwww.indiandentalacademy.com to avoid kinking.
Proper daily dressing should be done to prevent infection. When prosthesis is present, closed tube system should be used to lessen the risk of infection. It should not damage the nerve or blood vessel. The inner end should not be placed near suture lines. ď Ź
TYPES OF DRAINS: COTTON GAUZE Gauze acts as a drain by capillary action in the fabric which absorbs the fluid. Once it become saturated, it acts as a plug rather than as a drain. So should be changed twice daily or every 24 hrs. www.indiandentalacademy.com
USES: To pack a cavity to prevent its closure and to allow healing from floor or to control diffuse oozing. Ex: After incision and drainage of Injection abscess in gluteal or deltoid region. Breast abscess. ADVANTAGES: It acts as a temporary drainage. DISADVANTAGE: Soaked rapidly. Sealed with 6 hrs by fibrin network. When soaked- acts as a moist channel for penetration of bacteria. When a soaked gauze is removed, it is often followed by www.indiandentalacademy.com gush of accumulated fluid from the cavity.
When a pack is left in contact with raw surface, it damages the raw surface since it become adherent to it. When soaked in liquid paraffin – damage to raw surface is avoided but gauze decreases the absorption capacity.
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WICKS The wick is formed from threads of ligatures or suture material twisted together or bound loosely. Where source of drainage cannot be brought to surface, then a wick can be passed down to it. DISADVANTAGE: It becomes soaked by the fluid. When wick is made of folded gauze, it swells when it becomes soaked - will obstruct the tract. Can adhere to the surface. Requires frequent change because it becomes ineffective www.indiandentalacademy.com due to soaked fluid.
GLOVE RUBBER DRAIN A strip of glove rubber, which is made of latex, is used to drain the superficial dead space. It is a poor drain and gets blocked easily, but it is least irritant. USES: To drain dead space after removal of large subcutaneous lipoma, sebaceous cyst. After thyroidectomy. Drainage of abdominal wall wound if haematoma or infection is anticipated. DISADVANTAGE: It drains only deeper tissue since its surface sticks to the raw area. www.indiandentalacademy.com
RED RUBBER CORRUGATED DRAIN
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Made of red rubber which is available in form of unsterile sheets. From which the strips of required length and breath are cut and sterilized by autoclaving. With this drain, fluid reaches the surface by gravity . So it must be covered with the gauze pieces. ADVANTAGES: Drainage of the fluid occurs along the grooves of drain, so less chance of blockage. Red rubber is irritant, so it forms fibrous tract around it which is advantageous, if used in peritoneal cavity becz. When faecal fistula occurs, it can be controlled. This drain is used only when there is minimal amount of www.indiandentalacademy.com discharge.
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DISADVANTAGES: If used for prolonged period and removed at a time, it heals from superficial and deep and middle part are infected- forms sinus or pocket. Being tough material- injure intestine and cause faecal fistula- if kept for longer period becz. It may break the suture line. It might be sucked into the wound, when it is not fixed properly to surface. Currently portex drain is used instead of red rubber drain as a sheet drain as portex is less irritant than red rubber. USES: As per glove rubber drain. Drainage of the peritoneal cavity. www.indiandentalacademy.com Drainage of the perirenal areas after pyelolithitomy.
Drainage of large abscess cavity. To drain retro pubic space after surgery onto the bladder. To drain subcutaneous tissue after removal of multiple enlarged nodes in neck, groin, etc. After mastectomy.
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TUBE DRAIN When the fluid enters the tube, it can be guided into a collecting apparatus. ADVANTAGES: It forms closed drainage system so that raw surface cannot be contaminated due to entry of bacteria. www.indiandentalacademy.com
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DISADVANTAGES: It drains only in the direction of gravity. If the tube is too thin, force of capillary tends to retard the free flow of fluid through it. It cannot drain viscous fluid. It drains the fluid only when the tube is large, so fluid can be replaced by air. When continuous negative suction is applied to a tube drain, the tissue is drawn into the inner hole. (A) CATHETERS Types: Red Rubber Catheter. Malecot Catheter. www.indiandentalacademy.com Foley Catheter.
Their use is similar to that of sheet drain but are used particularly when the amount of drainage is high. ADVANTAGES: They can be directly connected to the apparatus, so contamination of wound with the drainage is less. DISADVANTAGES: The inner of the catheter can be blocked, by draining material obstructing the drainage. USES: To drain large abscess cavity. Drain liver abscess. To drain the infected hydatid cyst of the liver. To drain retropubic area after prostatectomy. To drain pelvic abscess. To drain peritoneal abscess. www.indiandentalacademy.com To drain the bladder after Freyer’s prostatectomy.
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(B) PORTEX DRAINAGE TUBE It is made of soft protex. It is elastic and has side holes as well as terminal holes at the tip. It is least irritant- can be used for prolong period. It has radio-opaque line along its length. Presterilized tubes are available. USES: To drain pleural cavity in Emphysema Hydropneumothorax Pneumothorax Haemothorax www.indiandentalacademy.com Postoperatively after operation on heart or lungs.
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PRECAUTION: Portex intercostal drainage tube should be connected to under water seal bottle by extension tubing. (C) YEATES DRAIN It is a sheet formed of parallel tubes of plastic material. DISDAVANTAGES: Very little fluid passes through the tubes once they are filled and it tends to track alongside the drain. (D) PENROSE DRAIN It is a hollow tube of latex rubber with thin wall and can be made by cutting the finger stall of surgical glove. Its tip is cut so that the ends are open. www.indiandentalacademy.com
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USES: As a cigarette drain. As a simple drain. For sump drainage of the peripancreatic retroperitoneal tissue in patients with infected pancreatic abscess. (E) CIGARETTE DRAIN Penrose drain that has gauze within it is called a cigarette drain. In cigarette drain, the ooze exists along and not through the gauze. The rubber acts as a conduit. USES: www.indiandentalacademy.com Advantages and uses are same as for Penrose drain.
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DISADVANTAGES: Secretion cannot be collected in bags, so it cannot be measured. Chances of infection are more than in Penrose but less than that of corrugated rubber drain. Skin irritation and excoriation may occur due to seepage of irritant effluent. (F) SHIRLEY DRAIN This drain is incorporated with a side tube guarded by a bacteria filter so that the sterile air can be drawn down to the tip of the drain. When a suction is applied to this drain, the air leak prevents tissues being sucked into the drain holes and blocking them. www.indiandentalacademy.com
(g) T-TUBE of
T-shaped with body and 2 flanges, this tube is made up polyvinyl chloride. It is available presterilized by gamma-rays or ethylene oxide.
• USES: To drain common bile duct.
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After chloedocoenterostomy, etc. REOVAL: If there is no residual stone in CBD or no anastomotic leakage, then on 22nd day T-tube is removed by sustained firm pull. PRECAUTIONS: Drains act as two-way conduits. Prophylactic use weighed against ensuing infection. Drain should be removed as soon as possible. It should never be brought about through the operative incision but through separate stab incision. Fix the drain properly with skin sutures. Drains should not be placed through an area where fibrosis will cause impairment of function. Do not drain bowel anastomotic suture line. Drains in peritoneal cavity may promote paralytic ileus and stimulate adhesionsresult in mechanical bowel www.indiandentalacademy.com obstruction.
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(h) SUMP SUCTION Sump drains are commercially available, but also be made by inserting one plastic tube within other. The outer tube projects for 2-3 cm outside the inner wound. The inner tube is longer and connected to the suction. Number of holes are made on the lower part of the outer tube, and the inner tube has single side hole, made close to its end. MECHANISM OF ACTION: A continuous current of air, activated by the suction, passes down through the outer tube and up through the inner tube. Any fluid collecting in the outer tube is immediately sucked away. No suction occurs at the opening in the outer tube, so www.indiandentalacademy.com surrounding tissues are not drawn against it.
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USES: In general sump suction is used to accomplish drainage against the force of gravity. To drain any part of peritoneal cavity. For irrigation, irritating fluid flow through the air vent while intermittent suction continues. Drainage of pancreatic, duodenal, jejunal and ileal fistulae. Drainage of pancreas following trauma. ADVANTAGES: Prevents skin damage from irritating secretions. Permits accurate measurement of the volume of drainage fluid. No vaccum plugging of the drain during continues low www.indiandentalacademy.com pressure suction.
DISADVANTAGES: Lack of pliability, so drain is uncomfortable to the patient. Erosion of surrounding tissues may occur. FIXATION: Sump drains should be fixed away from the vital structures if long-term use is contemplated. (I) PLASTIC TUBE DRAINS: TYPES Silastic tub~ connected to closed gravity drainage (sterile bag or bottle) or to a suction apparatus. Polyvinyl choride (PVC) tube attached to a suction apparatus or negative suction bottle, or closed gravity drainage. ADVANTAGES: Fluid is collected without soiling the surrounding skin. www.indiandentalacademy.com Accurate measurement of fluid is possible.
DISADVANTAGES: Suction cannot be applied to a single tube drain in peritoneal cavity, since suction would draw surrounding bowel and omentum against the tube causing damage to these structures and also all drainage would cease immediately. ď Ź USES: (A) Negative Suction Tube Drain (RedivacDrain) Drainage of wound to prevent haematoma, e.g. after thyroid surgery, astectomy, repair of incisional hernia when undermining is done and oozing of blood is anticipated. . After lymph node resection in axilla, groin or neck. After operation on hip or knee joints to prevent haematoma. www.indiandentalacademy.com ď Ź
(B) Plastic Tube without Suction After pyelolithotomy, ureterolithotomy or operation on urinary bladder when urinary bladder is opened. The drainage tube is put near the pel vi ureter area and retropubic area (cystolithotomy, suprapubic prostatectomy) to drain the leaking urine. After operation on extra-hepatic biliary tract to drain the leaking bile (sump drainage is preferred). T-tube, to drain common bile duct (CBD) after CBD exploration or surgery on it. (J) REDIVAC DRAIN PRINCIPLE: Active suction is applied in a continuous manner. So it does not allow the secretions to collect inside and indirectly also maintains potency of the drainage tube and does not allow the secretions to dry and occlude the drain site. It serves two purposes: www.indiandentalacademy.com The provision of access for accumulated pus or intestinal contents.
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The prophylactic removal of any fluid within the peritoneal cavity (e.g.bile) before their presence can lead to complications. This prophylactic drainage may be best accomplished by the use of close wound suction drainage. Also, it is more important where small amount of drainage and non-dependent drainage is required. ADVANTAGES: Less irritating to the tissues. Less likely to cause infection because it is a closed system. It is particularly effective under large skin flaps, e.g. after radical neck dissection, modified radical mastectomy. Closed suction drainage decreases the incidence of infection occurring secondary to contamination of the drain itself and is mandatory in the presence of a foreign www.indiandentalacademy.com body.
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EQUIPMENT: Negative suction bottle, either single or three. K-60/61 suction tube, usually from latex rubber, polyvinyl chloride and silas tic. I.V. set. Other types of suction drainage (pleurevac device) is used as a chest drain following thoractomy or intercostal drainage tube insertion-classic 3 bottle system is employed. Usually 15-20 cm of HP effective negative suction is applied. The effec-tiveness of active negative suction can be judged by observing collapsed Murphy's chamber. When this chamber is ballooned, negativity is lost. On such Removal of the drain should be done as soon as the www.indiandentalacademy.com discharge diminishes usually after 48-72 hours.
REMOVAL OF DRAIN: The prophylactically placed drain should be removed as soon as drain-J age has subsided, usually after 48 hours there is no need to shorten the drain. The therapeutically placed drain is kept in position until the drainage I subsides. Then it is removed gradually; a 3-4 cm of drain is withdrawn! each day and refixed to allow closure of the drainage tract from it! depth, thus preventing pocketing. Tube drains are removed when drainage output is minimal or has, ceased. Corrugated drains are usually removed on the third day or when there is cessation of discharge. The commonly used drains are corrugated rubber sheets www.indiandentalacademy.com and tubes
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