OPEN LEARNING ZONE

KEYWORDS Drains / Closed drains / Open drains

Provenance and Peer review: Unsolicited contribution; Peer reviewed.

Use of drains in surgery:

a review
by Rajaraman Durai, Abdoolla Mownah and Philip C H Ng
Correspondence address: R Durai MD MRCS, Department of Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH. E-mail : dr_durai@yahoo.com

Drains have been used in surgery for several years to remove body fluids thereby preventing the
accumulation of serous fluid and improving wound healing. Drains may be classified as closed or
open systems, and active or passive depending on their intended function. Closed vacuum
drains apply negative suction in a sealed environment, producing apposition of tissues and thus
promoting healing. Correct assessment of clinical indications might reduce unnecessary usage.
This article will introduce the principles and practice of various types of drains and highlight the
importance of understanding how surgical drains promote quality patient care.

Introduction Classification A) Closed drains

Surgical drains are manufactured tubes
that drain various bodily fluids and have
been used in surgery for several years. Their
application can be broadly classified as
prophylactic and therapeutic. Drains have
several functions. They remove body fluids
thereby preventing the accumulation of
serous fluid (seroma), and improving wound
healing. Seromas are a good nidus for
infection; they can cause discomfort and
are alarming for the patient.
Indications for the use
of a drain
Drains may be classified (Table 1) as closed 1 Vacuum drains
or open systems, and active or passive Vacuum drainage system (Redivac®,
depending on their situation and function. J-Vac®, abdominal VAC® drains)
A closed drain is one in which the contents
are not exposed to the atmosphere and Vacuum assisted closure device (VAC®)
these are further sub classified into vacuum
2 Non- vacuum drains
and non vacuum varieties. An open drain
communicates with the atmosphere. Closed Robinson drain
drains encourage an anaerobic environment
Mallecot
which may promote the growth of certain
bacteria. An active drain is one which is Pigtail drain
driven by negative pressure. A passive drain
is one that simply channels fluids. Chest tube drains with an underwater
seal

Prophylactic T- tube drain

1) To remove excess blood and serum

Type Examples of Closed Drains Examples of Open Drains
2) To remove pus, blood, serous exudates, Vacuum Redivac® Not applicable
chyle or bile J- Vac®
3) To form a controlled fistula e.g. after Abdominal VAC® drains
common bile duct exploration Vacuum assisted closure dressing

Therapeutic Non-Vacuum Robinson drain Corrugated drain

1) To drain pus, blood, serous exudates, Pigtail drains Sump drain
chyle or bile Mallecot Penrose drain
Chest tube drains
2) To drain air from the pleural cavity T tube drain
3) To drain ascites
Table 1 Classification of various drains

Open Learning Zone supported by

180 June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026


B) Open drains
Corrugated drain
Penrose drain
Sump drain
A1 Closed vacuum drainage systems
Closed vacuum drainage systems are closed
circuit suction drainage systems that are
designed to apply negative suction in a
sealed environment, producing apposition
of tissues and thus promoting healing.
Redivac®
The Redivac® system (Fig 1) is an example
of a negative pressure drain with a vacuum
that draws the fluids into a reservoir bottle.
The drain tube is available in variable sizes,
however the bottle is a single, standard size.
The drawback of this system is that when
the reservoir bottle is full, it needs to be
replaced. The clear reservoir allows
measurement of daily output but is prone to
Figure 1 Redivac® showing collection bottle with
vacuum in it
Figure 2 Vacuum assisted closure dressing
June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026
OPEN LEARNING ZONE
The J-Vac® drain is another form
of low negative pressure system
breakage if dropped. The presence of a
vacuum can be seen from the outside from
the retracted green rubber portion. When
there is loss of vacuum but the bottle is
empty, the vacuum can be recreated by
attaching the bottle to a suction machine.
When the drain needs to be removed, the
vacuum should be released first, otherwise
it can cause pain from the negative
pressure holding the tissues (Schein 2008).
The rate of haematoma and seroma
formation after face lift surgery decreased
significantly after using vacuum drains
during the first 24 hours (Perkins et al
1997). Project
Jackson-Pratt® drain
Explore your theatre stock room to
The Jackson-Pratt drain has a soft, pliable,
look at various drains, their sizes
silicone tube with multiple perforations and find out which ones are active
along the side and there is a bulb that can and which ones are passive drains.
be used to recreate the low negative
pressure vacuum, which also collects fluid.
As a low negative pressure suction system, Notional Learning Hours
it is designed so that intra abdominal
1 hour
contents such as the omentum or
intestines are not sucked into the tube,
minimising the risk of bowel perforation or Knowledge and Skills Dimension
ischaemia. Core 2: Personal and people
development
J-Vac® drain Core 4: Service improvement
The J-Vac® drain is another form of low HWB6: Assessment
negative pressure system. It has a silicone and treatment planning
tube with grooves at the body cavity end HWB7: Interventions and treatments
which form four tiny lumens. These join to
form a single lumen at the reservoir end. Its
main advantages are: it does not get
blocked easily by omentum, the vacuum
can be recreated at the reservoir without
having to change the reservoir, and the
Project
silicone material is less painful for the
patient. See various patients with drains
and find out the indications for the
Vacuum assisted closure (VAC®) devices
placement of drains and how they
VAC® devices are used for the closure of
affect the patient.
open wounds including limbs (figure 2),
the chest and the abdomen. Abdominal
VAC® dressings are used when primary
Notional Learning Hours
closure of a laparotomy wound is
1 hour
impossible because of increased pressure
in the abdomen, or when a relook
laparotomy may be needed in gross Knowledge and Skills Dimension
abdominal sepsis. The abdominal viscera Core 2: Personal and people
are protected by a porous non-adherent film development
on the top of which a sponge and polyfilms Core 4: Service improvement
are applied. A vacuum pad can be applied HWB6: Assessment
to create a negative pressure. Abdominal and treatment planning
VAC® drains have transformed the HWB7: Interventions and treatments
181
OPEN LEARNING ZONE
Use of drains in surgery: a review
Continued
Project
Look at J-Vac® and Redivac®.
Try to familiarise yourself with how
to reproduce the vacuum
Notional Learning Hours
30 mins
Knowledge and Skills Dimension
Core 2: Personal and people
development
Core 4: Service improvement
Core 5: Quality
HWB6: Assessment
and treatment planning
HWB7: Interventions and treatments
“
“
Review
Review the indications for various
drains and their complications
Notional Learning Hours
30 mins
Knowledge and Skills Dimension
Core 2: Personal and people
development
Core 4: Service improvement
HWB6: Assessment
and treatment planning
HWB7: Interventions and treatments
182
management of the septic abdomen and do
not need to be replaced for 48 hours. Figure
2 shows an example of vacuum assisted
wound dressing applied to the foot wound.
Even though VAC® dressings are a form of
wound dressing, they act like surface drains
rather than cavity drains and therefore
included under vacuum drains.
A2 Closed non-vacuum drains
Robinson drainage system
Wallace silicone drainage tubes are used in
this system (Fig 3). They have holes on the
Figure 3 Robinson type passive type of tube drain
with an attached bag
Figure 4 Pigtail drain for draining appendicular
abscess
Figure 5 Chest drain with an underwater seal
June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026
sides of the inner end. They are the most
commonly used closed passive drainage
system.
Mallecot drain
The Mallecot drain is a red rubber tube
drain with a self-retaining mushroomed end,
which is intended to cause fibrotic tissue
formation around it. It is useful whenever a
tract needs to be created. It can also be
used for open suprapubic cystostomies.
The drain is outdated and silicone drains
are used now because of possible latex
allergy.
Pigtails
Pigtails are small lumen self-retaining
drains, curled in the shape of a pigtail which
are used for draining a single cavity (Fig 4).
They are mostly used by radiologists for
ultrasound-guided or CT guided drainage
but are not useful in septated cavities or
when the pus is thick. Their patency can be
maintained by flushing them once or twice
every day as they are passive drains that get
blocked easily. Their removal requires the
cutting of a thread to unwind the self
retaining end before the drain can be pulled
out.
Chest tube drains
A chest tube drain (Fig 5) is a passive drain
similar to a Wallace drain but attached to an
underwater seal to provide a non-return
valve. The consistency of the tube is stiff so
it does not collapse easily but this causes a
lot of discomfort and is poorly tolerated. The
tube needs to be clamped during patient
transport. Suction can be applied to convert
a chest tube drain into an active drain.
‘T’ tube drains
These drains in the shape of a ‘T’ are used
after exploration of the common bile duct.
The duct is closed on the drain, and the long
part of the drain is brought out through the
abdominal wall to form a controlled external
biliary fistula. A cholangiogram can be
performed via this tube to assess the
patency of the bile duct and to exclude any
bile duct stones. The drain can be clamped
at seven days and if there are no signs of
biliary obstruction, it can be pulled out. The
fistula will close by itself provided there is no
distal obstruction in the bile duct.
B Open drains
Corrugated drain
The corrugated drain comes in the shape of
a red rubber corrugated sheet. This is now
 OPEN LEARNING ZONE

Sometimes the reservoir can be full

and the patient can develop a haematoma
from the residual collection.

replaced by silicone. The drain sheet can be
cut to the required size. It does not get
blocked easily. These drains may connect
the atmosphere and the inside of the wound
and therefore may introduce infection into
the wound. Corrugated drains are often
used in the treatment of diabetic foot
abscesses (Lawes & Refson 2004). A stoma
bag can be applied around the drain site to
collect the drain contents so that it will not
soil the patient’s clothes and bed, allowing
measurement at the same time. Usually a
safety pin is attached to the drain to prevent
it from migrating into the wound.
Penrose drain
A Penrose drain is a flat rubber ribbon-like
drain. A gauze dressing is applied around
the external end of the Penrose drain to
absorb the drainage fluid, which may
otherwise leak. The volume of drainage fluid
can be roughly estimated by weighing the
gauze swabs. Bacteria can enter and
colonise the wound because this drain is
exposed to the atmosphere. Often the drain
is left only for a few days to drain pus.
Therefore the bacterial colonisation is not
an issue in practice.
Sump drain
A Sump drain consists of a smaller inner
tube and a larger outer, perforated tube. It is
used for irrigation particularly in conditions
like necrotizing pancreatitis. Suction is
applied to the smaller inner tube and it
allows the drain to remain patent.
Diagnostic peritoneal drains
Peritoneal drains or diagnostic insertion of
Reference Surgery type
Erdem et al 1998 Limberg flaps for pilonidal abscess
Tander et al 2003 Uncomplicated perforated
appendicitis
Kim et al 2004 Gastric cancer surgery with
extended lymph node dissection
Aldameh et al 2005 Elective hepatectomy
Pothier 2005 Thyroid and parathyroid surgery
Kumar et al 2006) Uncomplicated total joint arthroplasty
Gurusamy & Samraj Incisional hernia repair
2007
Kumar et al 2007, Gastrectomy and gastric bypass
Dallal et al 2007
Table 2: Studies suggesting that routine use of a drain is unnecessary
umbilical vein catheter transperitoneally
may help to diagnose conditions such a
hollow viscus perforation and haemorrhagic
ascites. They are particularly useful in
resuscitating small critically ill infants with
necrotising enterocolitis (Ahmed et al
1998).
Drain fixation
The drains are usually fixed to the skin by
means of sutures, which are usually silk.
The exemptions are the radiologically-
inserted drain, and Penrose drains. Pigtail
drains are self-retaining. A safety pin can be
used to prevent migration of the drain into
the wound.
Drain removal
Although there is no scientific evidence
available, a generally accepted rule is that if
a drain produces less than 25ml in the
previous 24 hours (approximately 1ml/hr),
then it is safe to remove.
Complications
Drains are not without complications. They
can cause haemorrhage, tissue
inflammation, retrograde bacterial
migration and drain entrapment (Walker
2007). Drains sometimes break during their
removal, leaving a drain fragment in the
wound (Hak 2000). Abdominal silicone
drains may cause pressure necrosis and
can lead to bowel perforation (Nomura et al
1998). After prolonged use, a drain can
erode the bowel and may lead to an
enterocutaneous fistula. Suction drains may
increase the risk of postoperative infectious
Comments
No drains will result in shorter stays
Drains are not indicated
Prophylactic drain placement
does not offer additional benefit
Routine use of suction drains
is not necessary
Routine use of suction drains
is not essential
Routine use of suction drain
is unnecessary
Knowledge and Skills Dimension
There is no evidence to
recommend the use drains
Routine drainage is not necessary
Case study
A patient has a chest drain. How
will you monitor a chest drain and
what are the precautions that are
required while transporting such a
patient?
• Examine the dressing around the
drain and observe for signs of
leakage.
• Monitor the skin around the drain,
is it excoriated, irritated,
erythematous ? What can be
used to prevent skin damage
around drains.
• At each change of dressing the
retaining stitch is checked to see
if the drain is still securely
fastened.
• Monitor the characteristics of the
drainage: Rate, volume per shift
or 24 hours, quality, colour,
presence of blood and report
accordingly.
• Does a sample need to be sent to
determine the nature of the
drainage? Some drains may
require the application of a
collecting/ stoma bag around the
site to allow accurate
measurement.
Notional Learning Hours
30 mins
Core 2: Personal and people
development
Core 4: Service improvement
HWB6: Assessment
and treatment planning

June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026 183

OPEN LEARNING ZONE
Use of drains in surgery: a review
Continued
complications (Ghezzi et al 2003). Use of
drains may prolong the hospital stay and
therefore result in increased cost of
treatment (Alvarez Uslar et al 2005).
Contraindications
A drain should not be inserted in to a
haematoma with an underlying arterial
anastomosis, because the patient may
become hypotensive from depletion of blood
volume.
In certain cases a drain is not routinely
necessary (Table 2).
Discussion
Drains are used in a variety of clinical
situations. Drain sites are often painful and
it is useful to inject local anaesthetic around
the drain site both prior to their insertion
and prior to their removal (Yiannakopoulos
& Kanellopoulos 2004). Usually the amount
of drainage that is collected in the drain
reservoir is maximal in the first 24 hours.
Sometimes the reservoir can be full and the
patient can develop a haematoma from the
residual collection. Drain bottles should be
monitored frequently for the first 24 hours
after insertion (Williams et al 2003).
Surgical examples
Abdominal drains
Sump drains are often used after pancreatic
necrosectomy (Branum et al 1998). If the
pancreatic drainage fluid shows an amylase
>5000U on the first post-operative day, it
indicates a potential pancreatic fistula
(Molinari et al 2007). Early drain removal
within four days after a Whipples operation
reduces intra-abdominal infections(Kawai et
al 2006). Subcutaneous drainage in obese
patients may reduce seroma development
after cholecystectomy (Chowdri et al 2007).
After laparoscopic cholecystectomy, trocar
insertion sites may be used for inserting the
drains (Komuta et al 2000). Drains inserted
after laparoscopic Roux-en-Y gastric bypass
are helpful in detecting anastomotic leaks
(Chousleb et al 2004) because one can see
small bowel contents in the drain.
Abdominal drain sites are often colonised
184
with enterococcus and coagulase negative
Staphylococci which are resistant to
meticillin (Michalska et al 1997). A drain is
not essential after low rectal anastomosis
(Brown et al 2001).
Thyroid surgery
Drains are not essential after
uncomplicated thyroid surgery (Talmi 2004).
Drains prolong the hospital stay, increases
the risk of infection and treatment costs
(Suslu et al 2006, Lee et al 2006).
Haematomas still occur with drains in situ
(Karayacin et al 1997).
Orthopaedic surgery
Neither the insertion of drainage nor
clamping alter the transfusion rates after
knee replacement (Sundaram & Parkinson
2007, Kiely et al 2001). Transfusion
requirements are increased in hip
arthroplasty after using drains (Walmsley et
al 2005, Widman et al 2002). Drains
decrease the incidence of epidural
hematoma on the first postoperative day
after lumbar disc surgery (Mirzai et al
2006).
Breast surgery
Seromas are common after breast and
axillary surgery, often requiring needle
aspiration (Soon et al 2005). When
inserted, drains may be safely removed on
the second postoperative day (Yii et al
1995) although there is an increase in the
occurrence of seromas requiring further
treatment (Barton et al 2006). The use of a
buttress suture may reduce the seroma rate
after axillary clearance (Schuijtvlot et al
2002). It is beneficial to use drains both in
the breast and abdomen after breast
reconstruction using the TRAM flap (Scevola
et al 2002).
Chest drain
The most common error made while
inserting a chest drain is choosing a site
which is too low - far down below the safe
triangle which is bordered by the anterior
border of the latissimus dorsi, the lateral
border of the pectoralis major muscle, and
a line superior to the horizontal level of the
nipple (Griffiths & Roberts 2005). A chest
June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026
drain should be monitored by assessing the
swinging of the water column and air
bubbling. If there is no swinging, it means
the chest may be expanded fully or the tube
may be blocked. A chest X-ray will
demonstrate any residual pleural fluid,
pneumothorax and status of expansion of
the lung. The drain should be clamped when
changing the underwater seal bottle.
How do the drains affect the patient?
Having a drain may cause inconvenience to
the patient. It may delay the patient’s
discharge until it is removed. Drain sites can
be very painful. It may be difficult for the
patient to sleep comfortably with a drain
which can be get caught and inadvertently
pulled out. In the long-term, the drain site
may leave a puckered scar which may be
unsightly because it may be left to close by
natural healing.
Summary
Knowing the function and the current best
available evidence for using the drains may
reduce unnecessary insertions. The drains
are used for both prophylactic and
therapeutic purposes. Each drain has a
specific use. An active drain is one which is
driven by negative pressure. A passive drain
is one that simply channels fluids. Whilst
removing a drain, negative pressure, if
present, should be released first otherwise
it may cause pain. Redivac® is a commonly
used vacuum drain. J-Vac® is a special kind
of vacuum dressing where the vacuum can
be recreated by adjusting the reservoir.
Chest drains are attached to an underwater
seal and suction can be applied if there is
an air leak. Corrugated drains may introduce
bacteria into the wound and are used in
diabetic foot abscesses. Pigtails are
radiologically inserted and Penrose drains
are flat rubber like and are very rarely used.
Drains can cause bleeding, inflammation
and can break during their removal. A good
understanding of how various types of
drains work will help to monitor their
function and contribute to better care of
drains and the patient.

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necrotizing enterocolitis: recommendations from
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Aldameh A, McCall JL, Koea JB 2005 Is routine
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Brown SR, Seow-Choen F, Eu KW, Heah SM, Tang
CL 2001 A prospective randomised study of drains
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Hak DJ 2000 Retained broken wound drains: a
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M, Gongal R 2007 Is prophylactic placement of
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foot Annals of the Royal College of Surgeons
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Talamini G, Falconi M, Pederzoli P 2007 Amylase
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OPEN LEARNING ZONE
Nomura T, Shirai Y, Okamoto H, Hatakeyama K
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report of two cases Surgery Today 28 (9) 940-2
Perkins SW, Williams JD, Macdonald K, Robinson EB
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prospective audit of the use of a buttress suture to
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Soon PS, Clark J, Magarey CJ 2005 Seroma
formation after axillary lymphadenectomy with and
without the use of drains Breast 14 (2) 103-7
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drains do not increase the blood transfusion rates
in patients undergoing total knee arthroplasty
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185
OPEN LEARNING ZONE

Use of drains in surgery: a review

Continued

Yiannakopoulos CK, Kanellopoulos AD 2004

Innoxious removal of suction drains Orthopedics
27 (4) 412-4
Yii M, Murphy C, Orr N 1995 Early removal of
drains and discharge of breast cancer surgery
patients: a controlled prospective clinical trial
Annals of Royal College of Surgeons England
77 (5) 377-9
Additional Learning Resources
Associated AfPP online modules:
• Skin Preparation
• Infection Control
• Universal / Standard Precautions
• Patient Care in the Operating Department
Reflective model
You will find several reflective module templates
for you to utilise when utilising reflective practice
for your CPD under the career development tab
on the AfPP web site.

About the authors Members can search all issues of the BJPN/JPP
published since 1998 and download articles free of
Rajaraman Durai charge at www.afpp.org.uk.
MD MRCS Access is also available to non-members who pay a
Specialist Registrar, Department of Surgery, small fee for each article download.
University Hospital Lewisham, London

Abdoolla Mownah
MD FRCS
Consultant Surgeon, Noble’s Hospital, Isle of Man

Philip C H Ng
MD FRCS
Consultant Surgeon, Department of Surgery,
University Hospital Lewisham, London

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186 June 2009 / Volume 19 / Issue 6 / ISSN 1467-1026

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