leading to faeculent peritonitis (Benjamin. 1980), internal ... Benjamin, P. J. (1980) Facculcnt peritonitis: a compli- ... Gynaecological Surgery (Stanton, S . L., ed.),.
British Journal of Obstetrics and Gynaecology October 1988, VoI. 95, pp. 1063-1069
Surgical wound drainage: a survey of practices among gynaecologists in the British Isles PAUL HILTON Summary. All 2836 members and fellows of the Royal College of Obstetricians and Gynaecologists were circulated with a questionnaire concerning their practices with regard to wound drainage. The overall response rate was 43%, although that from practitioners of consultant and senior registrar status was 67%. The use of wound drainage was consistent between surgeons of differing levels of experience and different subspecialty interests within gynaecology. At routine ‘clean’ operations the use of drains is limited; only 0.4%of gynaecologists drain the peritoneal cavity, 1% the pelvis, 4% the subcutaneous tissues, and 20% the rectus sheath routinely. At more specialist ‘clean’ procedures, however, greater use of drains is made; at suprapubic incontinence operations 51% of surgeons drain the retropubic space; at radical hysterectomy 55% drain the pelvis; and at radical vulvectomy 63% use drains in the groins, routinely. In all the above operations much greater use is made of active (83%) than passive drains (17%)).With potentially contaminated wounds, however, 46% of gynaecologists use a passive drain.
It was originally stated by Halstead (1898) and often repeated since (Cruse & Foord 1973; Agrama etal. 1976; Magee etal. 1976; Moss 1981; Helmkamp, Krebs & Amstey 1984) that drains must not be considered a substitute for haemostasis nor a replacement for meticulous surgical technique. The place of, and most appropriate techniques for, drainage in surgical practice have always been the source of contention. Price (1888) put forward the view, perhaps not unrepresentative of current practices; ‘There are those who ardently advocate it-there are those who in great part reject it-there are those who, Laodicean-like, are University of Newcastle-upon-Tyne, Department of Obstetrics and Gynaecology, Princess Mary Maternity Hospital, Great North Road, Newcastleupon-Tyne NE2 3BD PAUL HTLTON Senior Lecturer and Honorary Consultant
lukewarm concerning it, and finally, some who, without convictions, are either for or against it, use it or dispense with it, as chance or whim, not logic may determine’. Drains are used thcrapeutically in the presence of purulent material, necrotic debris, a fistula or to prevent premature closure of a wound. The prophylactic use of drains is intended to prevent the accumulation of blood, lymph, urine, pus, intestinal contents, bile or pancreatic secretions, and occasionally to permit the early detection of surgical complications. It is in this latter context that the use of drains is perhaps most controversial (Helmkamp et al. 1984), and it is here that the gynaecologist is most frequently concerned. Whilst there is a considerable surgical literature regarding the different techniques of wound drainage, there is little information concerning actual practices among gynaecologists. The aim of this study was to establish current practices with respect to wound drainage among gynaecologists in the British Isles.
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P. HiZton
Methods All members and fellows registered with the Royal College of Obstetricians and Gynaecologists (RCOG) at the end of 198.5 and resident within the British Isles were circulated with a two-part reply-paid questionnaire relating to their use of catheters and surgical drains; results of the catheter survey form the basis of a separate publication (Hilton 1988). In the second part of the questionnaire respondents were requested to indicate whether they would routinely, selectively, or never use drains in the pelvis, peritoneal cavity, rectus sheath, or subcutaneous tissues at a variety of obstetric and gynaecological procedures; in those situations in which drainage was advocated they were asked to state what type of drain was used, and in particular to indicate whether a suction or passive drain, and an open or closed system, were preferred. In an effort to assess regional variations in practice and the influence of experience and specialist interests within gynaecology, respondents were also asked to state the time since they had obtained membership of the RCOG, the region in which they were currently employed, whether they had a major specialist interest in gynaecological oncology or urology, and the extent of their surgical workload in general gynaecology or in these specialist areas.
Results
Respondents A total of 2836 questionnaires was distributed and 1216 were returned, giving an overall response rate of 43%. Of the returns, 269 were uncompleted: 153 from retired members or fellows, 84 from members practising in specialties other than obstetrics and gynaecology, 29 were returned by the Post Office undelivcred, and three were returned by relatives of deceased members or fellows; 947 completed questionnaires were returned by members and fellows currently active within the specialty-‘the appropriate respondent~’-(780/~ of returns; 33% of the circulation). Of the 947 appropriate respondents 683 (72%) were of consultant status, 130 (14%) of senior registrar status, and 115 (12Y0) were registrars; the remaining 19 (2%) were made up of hospital practitioners, clinical assistants, senior house officers or of unspecified status. Based on predicted figures
for 1986 from the Report of the Manpower Advisory Sub-Committee of the RCOG (1983) the response rate from consultants was approximately 65% and from senior registrars 78%. Of the 947 appropriate respondents 183 (19%) considered themselves to have a major specialist interest in gynaecological urology; in subsequent analysis the practices of the other 764 generalist surgeons were compared with those of the 183 who claimed a major specialist interest in gynaecologic urology, and with practices of 47 surgeons who had a significant surgical workload in the subspecialty-arbitrarily defined for these purposes as more than 25 suprapubic incontinence procedures per year. A total of 178 (19%) of the appropriate respondents considered themselves to have a major specialist interest in gynaecological oncology; again, the practices of the other 769 surgeons with no particular interest in gynaecological oncology were compared with the practices of those claiming a major specialist interest and with the practices of 56 respondents who had a significant surgical workload in the subspecialty, defined for these purposes as more than 2.5 radical cancer procedures per year.
The use of drains The number of surgeons employing drains on a routine or selective basis at a variety of obstetric and gynaecological procedures is shown in Table 1 and Fig. 1. At what one might call routine ‘clean’ operations (caesarean section, abdominal hysterectomy, and ovarian cystectomy) the use of drains on a routine basis is limited; averaging for these procedures, only 0.4% of gynaecologists drain the peritoneal cavity routinely, 1% drain the pelvis. 4% the subcutaneous tissues. and 19% the rectus sheath. With potentially contaminated wounds, following appendicectomy or other bowel surgery, the routine use of drains is similarly limited, although at more specialist ’clean’ procedures, particularly where large parietal spaces are dissected, greater use of drains is made. At suprapubic incontinence operations 50.7% of surgeons drain the pelvis or rectus sheath (both presumably implying the retropubic space) ; at radical hysterectomy 55-5% drain the pelvis; and at radical vulvectomy 63.5% use drains in the groins.
Surgical wound drainage practice Table 1.
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The use of drains by gynaecologists in thc British Isles Percentage or respondents using drains routinely (selective use shown in parenthe5es)
Surgical procedure Caesarean section Transverse incision Longitudinal incision Abdominal hysterectomy Ovarian cystectomy Appendicectomy Other bowel surgery Suprapubic incontinence opcration Radical hysterectomy Radical vulvectomy
Pelvis 0.3 (14.3) 0.4 (14.1) 3.1 (57.5) 0.2 (18.8) 1.5 (31-7) 6.8 (50.8)
15.9 (13.5) 55.5 (28.0) 8-8 (3.8)
Peritoneum
Rectus sheath
Subcutaneous
0.0
22.8 (45-5) 4.9 (27-0) 19-8 (47.5) 15.9 (37-4) 30.4 (19.6) 6.7 (33.8)
(22-2) 1.7 (1 7-7) 4-2 (24-8) 3-5 (18-2) 0.9 (13.4) 2.1 (19.4)
(11.9) 0.2
(12.2) 1.4 (29.1) 0.2 (15-5) 1.0 (40.4) 6.3 (48.9)
6-8 (6.9) 13.8 (28-1) 1-1 (2.9)
33.7 (26.4) 22.4 (39.6) 7-4 (4.1)
44
5.4 (1 7.3) 3.7 (20-9) 633 (12.5)
The figures quoted for each operation are the percentage of gynaecologistsusing drains routinely in the sites listed; figures shown in parentheses are those using drains in selected cases only.
Drain types In all the ‘clean’ procedures referred to above much greater use is made of active than passive drains (see Table 2 ) ; averaging for all thcse procedures, 17% of gynaecologists favour a passive type of drain, and X3% an active suction drain; of the latter, 81% use high-pressure and 12% low-pressure drainage systems (7% being unspccified). Following bowel surgery greater advocacy of passive drains is apparcnt. Here, of those gynaecologists using drains, 46% employ passive drains; where suction drains were used, however, the proportion of surgeons advocating high- and low-pressure drain systems was similar to those with ‘clcan’ wounds.
The effect of specialist interest The influence of a subspecialty interest in urology or oncology on surgeons’ practices with regard to wound drainage is examined in Table 3. Although there is a tendency for those individuals with an intercst in gynaecological urology to drain the retropubic space more frequently following suprapubic incontinence sur-
gery, and for those with an intercst in gynaecological oncology to drain the pelvis more frequcntly following radical hysterectomy, these differences are not statistically significant ($ test). Discussion
In a parallel study into practices with regard to bladder drainage amongst gynaecologists in the British Isles (Hilton 1988), considerable variations in practices were identified between surgeons of differing experience and differcnt levels of interest in gynaecological subspecialties; regional variations were also seen. Although considerable variations in practices are evident in the present survey, as found in previous surveys among general surgeons (Smith & Gilmore 19X5), the above associations were not recognized. Closed wound suction was first employed by Raffl in 1952, and the use of the portable closed wound suction unit was introduced by Redon & Jost in 1954 (reviewed by Moss 1981). Such systems may be said to be almost synonymous with wound drainage in current surgical prac-
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P. Hilton
Caesarean (transverse incision)
Appendicectomy
Caesarean (longitudinal incision)
Other bowel surgery
Abdominal hysterectomy
Ovarian cystectomy
Suprapubic incontinence surgery
100
60
20
Radical hysterectomy
Radical vulvectomy
100
80 60 40
20
0
Fig. 1 . Overall use of drains. For each operation the percentage of gynaecologists using drains routinely or in selected cases in the pelvis, peritoneal cavity, rectus sheath, or subcutaneous tissucs is shown by the tirst four columns; the right-hand column shows the percentage using passive and active drainage systcms at thc appropriatc procedure. 9, Routine drainage; 0, selective drainage; 8 , suction drain; passive drain.
.,
Surgical wound drainage practice
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Table 2. The use of drains by gynaccologists in the British Isles Perccntagc of respondents using Specified suction drain pressure Surgical procedure Caesarean section Transvcrse incision Longitudinal incision Abdominal hysterectomy Ovarian cystectomy Appendicectomy Other bowel surgcry Suprapubic incontinence operation Radical hysterectomy Radical vulvectomy
Passive drains
Suction drains
High
Low
Unspecified
14 21 19 17 48 44
86 79 81 83 52 56
82 82 81 81 77 78
11 12 12 13 14 13
7 6 7 6 9 9
11 24 15
89 76 85
81 78 80
11 14 12
8 8 8
The figures quoted are the percentage of clinicians using drains in the listed operations who employ passive and active drainage systems; to the right are shown the pcrcentage of those employing active drains who specified highor low-prcssurc suction.
tice, and this fact is emphasized by their consistent and widespread use in all the operations examined where drainage of some sort is used. These drains are typified by the original reusable ‘Redivac’ system, although many disposable portable suction devices are now available with either high (300-500 mmHg) or low pressure (1W150 mmHg). The question of optimum suction pressure was investigated by Britton etal. (1979); they found that low-pres-
sure drains collected more fluid, and were required to stay in place longer than high-pressure systems, and required frequent recharging. Infection has been shown to spread retrogradely via low-pressure suction systems, and this occurs particularly at the time of recharging (Lumley e t a f . 1974); however, this may be obviated to some cxtcnt by the incorporation of a non-return valve as in some available systems (Secley et al. 1979). High-pressure systems require little or no
Table 3. Thc effcct of surgeon’s level of interest in gynaecologcal urology or oncology on the use of routinc wound drainage at suprapubic incontinence surgery, radical hysterectomy and radical vulvectomy respectively Percentage of respondents using drains routinely Surgical procedure Suprapubic incontinence surgcry Generalist surgeons ( n = 866) Major urology interest ( n = 183) Major interest with >25 suprapubic operationsiyear (n = 47) Radical hysterectomy Generalist surgeons ( n = 826) Major oncology interest (n = 178) Major interest with >25 radical opcrationsiycar (n = 56) Radical vulvectomy Generalist surgeons ( n = 821) Major oncology interest (n = 169) Major interest with >25 radical operationsiyear ( n = 56)
Pelvis
Peritoneum
Rectus sheath
Subcutaneous
16 19
7 5
35 33
5 7
19
2
47
4
55 64
14 12
22 23
4 4
65
9
24
5
9 11
1
0
7 I
63 74
10
0
7
60
n , Number of responses. the disparities in numbers reflect different response rates to various questions.
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P.Hilton
recharging, and are therefore relatively free from this complication; their usc at hysterectomy has been shown to reduce the frequency of febrile morbidities from 25% to 11% and from 32% to 8% at abdominal and vaginal operations respectively (Schwartz & Tanarce 1975, 1976). A significant disadvantage of high-pressure systems, however, is that tissue encroachment into the tubing holes may impair drainage and causc tissue damage; their use in the peritoneal cavity has been associated with bowel trauma leading to faeculent peritonitis (Benjamin 1980), internal hernia formation (Fulham & Pritchard 1985), and evisceration (Shoukris & Kiff 1984). Their use in therapeutic drainage of hacmatomata or frankly contaminated wounds is similarly undesirable since they are likely to obstruct more rapidly with purulent material or clot (Hilton 1987). It is thus perhaps somewhat surprising that of those surgeons advocating the use of routine drainage following bowel surgery, over half employ suction drains, and over threequarters of those use high-pressure systems in this situation. Based on a review of the literature, several recommendations relating to the use of drains in gynaecological practice have been made (Hilton 1987). Several of these recommendations are confirmed as the majority practice in this survey; they may be summarized as follows. In abdominal and gynaecological surgery there is no evidence to support the routine use of peritoneal drains; however, where drains are used. a ‘closed’ passive system such as the Robinson drain or an ‘open’ active drain (sump drain) with a bacterial air inlet filter should be employed. Silicone is the preferred material since it generates the least tissue reaction. For drainage of the parietes, e.g. the rctropubic space at suprapubic incontinence surgery, or the groins at radical vulvectomy, closed wound suction drainage using high vacuum prcssure is the most effective in obliterating ‘dead space’ and reducing the risks of infection. Therapeutic drainage, of haematomata, frankly contaminated wounds, or abscess cavities is perhaps the only place in which an ‘open’ passive drain may be shown to be beneficial, but even here an ‘open’ active drain (sump drain) with an air inlet filter, or low-pressure ‘closed suction drain’ may again be used to advantage. High-pressure active drains are not recommended since they may obstruct more rapidly with purulent material or clot.
Whcre drains arc left in proximity to blood vessels, nerves. bowel, or bladder, they should be of a soft material. If suction is to be applied it should be either vented ‘open’ or of low prcssure, and tubing holes should he small. Drains, whether active or passive, should never exit through the operative incision, if infection, dehiscence, and hernia formation are to be minimized. Drains should be rcmoved as soon as clinically significant drainage ceases. For prophylactic drains this will usually be within 24-48 h of operation, although may be much longer following lymphadenectomy. Drains placed prophylactically can be removed straight away; those used therapeutically should be advanced by 3-5 cm per day once drainage has ceased. References Agrama, H . M . , Blackwood, J. M . , Brown, C. S., Machicdo, G. W. & Rush, €3. J. (1976) Functional longevity of intrapcritoneal drains. A m J Surg 132, 418-421. Benjamin, P. J . (1980) Facculcnt peritonitis: a complication of vacuum drainagc. Br J Surg 67, 453-454. Britton, B. J . , Gilmore, 0. J . A ,. Lumley, J. P. S. & Castleden, W. M. (197Y) A comparison between disposable and non-disposable suction drainagc units: report of a controlled trial. Er J Surg 66,279280. Cruse, P. J. E. & Foord, R. (1973) A five year prospcctive study of 23,649 surgical wounds. Arch Surg 107, 206-210. Fulham, S . B. & Pritchard, G . A. (1985) Internal hernia following T-tube drainage. Br J Surg 72, 519. Halstcad. W. S. (1898) Concerning drainage and drainage tubes. Trans A m Surg Assac 16, 103. Helmkamp. B. F., Krebs, H. B. & Amstcy. M . S . (1984) Correct usc of surgical drains. Contemp. Ubsiet Gyn.eco1 24, 123-130. Hilton, P. (1987) Catheters and drains. In Principles of Gynaecological Surgery (Stanton, S . L., ed.), Springer Verlag, Berlin, pp. 257-283. Hilton, P. (1988) Bladder drainage: a survey of practices among gynaecologists in the British Isles. Br J Ohstet Gynuecol (in press). Lumley, J. S. P., Britton, B. J . & Chattopadhyay, B. (1974) The physical and bacteriological properties of disposable and non-disposable suction drainage units in the laboratory. Br J Surg 61, 832-837. Magee, C., Rodeheaver, G. T., Golden, G . T., Fox, J. & Edgerton, M. T. (1976) Potentiation of wound infection by surgical drains. A m J Surg 131, 547549. Moss, J . P. (1981) Historical and current pcrspectives
Surgical wound drainage practice on surgcal drainage. Surg Gynecol Obstet 152, 517-527. Price, J. (1888) Drainagc in abdominal surgery. Trans Am Assoc Obstel Gynecol 1, 84. Royal College of Obstctricians and Gynaecologists (1983) Report of the Manpower Advisory SubComrnittcc-a consultative document. RCOG, London. Schwartz, W. H. & Tanaree, P. (1975) Suction drainage as an alternative to antibiotics at hystcrcctomy. Obstet Gynecol45, 305. Schwartz, W. H. & Tanarcc, P. (1976) T-tube suction drainage and/or prophylactic antibiotics: a ran-
1069
domised study of 451 hysterectomies. Surg Gynecol Obstet 47, 665. Seeley, M. F., Hyde, W. A. & Irving, M. (1Y79) A safe and effective disposable low pressure suction drain. Rr J Surg 66, 657-659. Shoukris, M. & Kiff, E. S. (1984) Withdrawal of thc appendix with an abdominal tube drain., Br J Surg 71, 401-402. Smith, S. R. G . & Gilrnore, 0.J. A. (1985) Surgical drainage. Br J Hosp Med 33,308-315. Received I November 1987 Accepted 13 December 1987
