Wound Drain​

Controversial measure with few recommendations

Why wound drain is not recommended routinely​

Illustration of a leg injury
“…most meta-analyses showed a tendency towards a beneficial effect
of not using a wound drain with regard to a reduced risk of wound infection, but no significant differences were achieved.”1

A statement of the 19th century British surgeon Lawson Tait, “When in doubt, drain”, has led to a widespread routine prophylactic postoperative placement of drains.1

But since then, a number of studies have been published questioning the benefits of routine wound drainage.1,2

The prophylactic use of drainage of enteric anastomoses is said to be associated with an increased risk of anastomotic breakdown and fistula formation.3

Guidelines

Guidelines
GuidelineRecommendation Category (if mentioned)
CDC4“If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible.”Category IB
WHO1“The panel suggests that perioperative antibiotic prophylaxis should not be continued to the presence of a wound drain for the purpose of preventing SSI.”

Conditional recommendation,

low quality of evidence

“The panel suggests removing the wound drain when clinically indicated. No evidence was found to recommend an optimal timing of wound drain removal for the purpose of preventing SSI.”

Conditional recommendation,

very low quality of evidence

NICE5--
KRINKO6Wound drains should not be used routinely, but only when specifically indicated and for the shortest time possible. Open drains should not be used because of the risk of infection. If drains are indicated, they should be drained via a separate incision.-

HARTMANN:​

Denise Leistenschneider, Senior Clinical Consultant
"The use of drains should be critically considered in light of the study evidence."

What is recommended?​

Icon of the arrow in circle

Drainage type:4
use closed suction drain

Icon of the arrow out

Drainage placement:4,6
through a separate incision away from the surgical incision

Icon of a clock

Drainage removal:4,6
remove drain as soon as possible

Indications for surgical drainage in abdominal surgery

Some possible indications for surgical drainage are:3

  • “Decompression" of viscus (e.g. duodenostomy, T-tube in common bile duct)
  • Large potential dead space (e.g. abdominoperineal resection, abscess cavity)
  • Insecure closure of hollow viscera (e.g. duodenum) – may provide an early warning of fistula
  • Established or potential fistula (e.g. gastrointestinal, biliary and pancreatic)
  • Presence of necrotic or infected tissue
  • Doubtful haemostasis – may provide an early warning of "haemorrhage”

Comparison of active and passive drain3

Active drainPassive drain
FunctionWorks by negative pressure created by compressible drums or mechanical education systemDepends on pressure differentials and gravidity
Pressure gradientLow to moderate negative – 100 to 150 mmHg
High negative – 300 to 500 mmHg (sump only)
Positive
Drain site dressingMinimal or not requiredIncreased incidence because of limited effect on the dead space
Fluid collectionsDecrease incidence because negative pressure improves tissue apposition and obliterates dead spaceIncrease incidence because of limited effect on the dead space
Retrograde infectionLower incidence especially with closed suction systemHigher incidence with open system
Radiographic studies via drainEasy to performDifficult except in special circumstances, e.g. T-tube and NGT
Pressure necrosisGreater incidenceLess common

NGT = nasogastric tube. Table modified from Memon et al. 2002

Possible complications of drains3

  • Haemorrhage, fistula and perforation because of erosion
  • Inflammation
  • Impaired healing
  • Leackage
  • Pain
  • Postoperative pyrexia
  • Fluid, electrolyte and protein loss
  • Pneumoperitoneum, pneumothorax
  • Surgical emphysema
  • Excessive fluid secretion
References
  1. WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
  2. Sagar PM, et al. (1993) Randomized trial of drainage of colorectal anastomosis. Br J Surg 80(6): 769–771.
  3. Memon MA, et al. (2002) The uses and abuses of drains in abdominal surgery. Hospital Medicine 63(5): 282–288.
  4. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
  5. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020. www.nice.org.uk/guidance/ng125.
  6. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.

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