Drains in oral surgery

DRAINS IN ORAL AND
MAXILLOFACIAL
SURGERY

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INDIAN DENTAL ACADEMY
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CONTENTS
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Definition
Purposes
Principle
Advantages
Disadvantages
Sites of drain placement
Drain placement
Types of drains
Cotton Gauze
Wicks
Glove Rubber Drain
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

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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.

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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.

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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 wall 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.


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.

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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
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.



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
due to soaked fluid.

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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.

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
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.
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.



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.



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.
Foley Catheter.

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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.
To drain the bladder after Freyer’s prostatectomy.



(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
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.

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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:
Advantages and uses are same as for Penrose drain.



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.

(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 adhesions- result in mechanical bowel
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
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
pressure suction.

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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.
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.
 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.


( 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:
The provision of access for accumulated pus or intestinal
contents.



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
body.



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 effectiveness 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
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 and tubes

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