Intra-abdominal drainage for laparoscopic cholecystectomy: A systematic review and meta-analysis

Evisceration of appendix via drain site - a rare complication in a child

INTRODUCTION AND IMPORTANCE

Abdominal drains prevent fluid accumulation and help drain fluid (blood, pus). In recent years, abdominal drains have been used less frequently due to drain-associated complications, like infections, anastomotic leakage, and the potential for the evisceration of intra-abdominal organs on drain removal.

CASE PRESENTATION

We present a young female with evisceration of the appendix via the drain site, successfully managed by abdominal exploration and appendectomy.

CASE DISCUSSION

The use of prophylactic abdominal drain is controversial and is of limited use even in complicated appendicitis in the modern era of antibiotics. If a drain is inserted, it should be removed at the earliest to avoid associated complications.

CONCLUSION

Abdominal drain usage should be minimized in children to avoid post-operative complications.

Saline irrigation versus gauze wiping and suction only for peritoneal decontamination during laparoscopic repair for perforated peptic ulcer disease

The aim of current single-center study was to compare the short-term outcome of suction and gauze wiping alone versus the irrigation and suction technique for peritoneal decontamination among patients who underwent laparoscopic repair of PPU. Using data from our institution's prospectively maintained database, 105 patients who underwent laparoscopic repair were enrolled in this study. The participants were further divided into the group who received peritoneal irrigation (irrigation group, n = 67) and group who received gauze wiping and suction only (suction only group, n = 38). The irrigation group had a longer operative time (140 vs. 113 min, p = 0.0001), higher number of drainage tubes (38.8% vs. 0%, p < 0.0001) and a higher incidence of intra-abdominal abscess (10.4% vs. 0%, p = 0.0469) than the suction only group. Peritoneal irrigation may be associated with a prolonged operative time and a higher number of abdominal drains. Meanwhile, gauze wiping and suction may be sufficient for peritoneal decontamination during the laparoscopic repair of PPU as further infectious complications are not observed.

The effect of abdominal drainage on post-operative morbidity; a prospective cohort study

The aim of this study was to investigate the effect of drains used in current clinical practice on operation parameters and post-operative morbidity. The comprehensive data obtained through the prospective design were analysed in detail according to whether abdominal drainage was applied. Abdominal drainage was present in 44.1% of patients who met the inclusion criteria. Drains were placed significantly more frequently during oncologic surgery (p = .007). The mean mobilisation (p = .001), first flatus (p = .001), and first oral intake (p = .029) times were longer in the drain group than those in the non-drain group. In patients who underwent oncological surgeries, no significant differences were observed except for the pre-operative duration of bowel preparation (p = .006) and first flatus time (p = .003). Our results suggest that drain placement in gynecological procedures does not provide an additional advantage.IMPACT STATEMENTWhat is already known on this subject? Post-operative drainage of the abdominal cavity has been controversial for many years. However, whether abdominal drainage provides an additional benefit in lower and upper abdominal surgical procedures remains unclear.What do the results of this study add? Most studies have examined post-operative pain and surgical site infections. We examined the relationship between abdominal drainage and demographic and pre-/post-operative clinical features in detail. We demonstrated that abdominal drainage in gynecological procedures may not provide an additional advantage.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information that can guide physicians in deciding whether to use post-operative abdominal drainage. This topic warrants investigation with randomised data in the future.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

PURPOSE

This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC).

METHODS

This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC.

RESULTS

A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI.

CONCLUSION

This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Treatment strategies of drain after complicated laparoscopic cholecystectomy for acute cholecystitis

Acute cholecystitis (AC) is the most common biliary tract disease, and laparoscopic cholecystectomy (LC) is recognized as the treatment of choice. The present study in this issue compared the surgical outcomes, particularly the occurrence of postoperative surgical site infections (SSIs) in patients with and without drain placement following complicated LC for AC. It showed that late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications, postoperative hospital stay, and SSIs. Drain placement is not routinely recommended, even after complicated LC for AC. When placing a drain, early drain removal is recommended for postoperative outcomes such as SSIs.

Day-only elective cholecystectomy: early experience and barriers to implementation in Australia

BACKGROUND

Day-only laparoscopic cholecystectomy (DOLC) has been shown to be safe and feasible yet has not been widely implemented in Australia. This study explores the introduction of routine DOLC to Westmead Hospital, and highlights the barriers to its implementation.

METHODS

Routine day-only cholecystectomy protocol was introduced at Westmead Hospital in 2014. A retrospective review of patients who underwent elective laparoscopic cholecystectomy during a 12-month period in 2014 was compared to a 12-month period in 2018, to examine the changes in practice after implementation of a unit protocol. Data were collected on patient demographics, admission category, outcomes and re-presentations.

RESULTS

A total of 282 patients were included in the study, of these 169 were booked as day procedures, with 124 (73%) successfully discharged on the same day. There was a significant increase in the proportion of patients booked as day-only from 2014 to 2018 (48% versus 73%, P < 0.001). Day-only failure rates (unplanned overnight admissions), readmissions and complication rates were comparable between the two periods. The most common reason for unplanned overnight admissions were due to intraoperative findings (n = 28/45).

CONCLUSION

Routine DOLC can be adopted in Australian hospitals without compromise to patient safety. Unplanned overnight admission is predominantly due to unexpected surgical pathology and can be reduced by protocols for the use of drains and planned outpatient endoscopic retrograde cholangiopancreatography. Unplanned outpatient review can be minimized by optimizing both intra- and post-operative pain management. Individual surgeon and anaesthetist preferences remain an obstacle to a standardized protocol in the Australian setting.

Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.

STUDY DESIGN

A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.

RESULTS

Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.

CONCLUSION

The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.

LEVEL OF EVIDENCE

Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence.

The effect on morbidity of the use of prophylactic abdominal drain following elective laparoscopic cholecystectomy

Background and Objective

To evaluate the clinical role of the routine use of a drain in an elective laparoscopic cholecystectomy operation applied to patients with symptomatic cholelithiasis not showing acute inflammation.

Method

Following laparoscopic removal of the gallbladder, patients were separated into two groups of 30 each, either with subhepatic drain placement or without. The presence of subhepatic fluid collection was evaluated with transabdominal ultrasonography (USG) at 24 hours postoperatively and on the 7th day. The other parameters evaluated were postoperative morbidity, shoulder and abdominal pain.

Results

No statistically significant difference was found between the two groups in respect of demographic characteristics and operative details. The median pain score was determined to be statistically significantly higher in the group with a drain applied compared to the group without a drain (p=0.007). In the comparison between the groups of fluid collection on USG at 24 hours and shoulder pain persisting until the 7th day, although seen less in the group with no drain applied, no statistically significant difference was determined (p=0.065, p=0.159). In the examinations made on the 7th day, no hematoma or significant fluid collection was determined on USG and no wound infection was observed in any patient of either group.

Conclusion

The routine application of prophylactic subhepatic drain in laparoscopic cholecystectomy procedure did not show any benefit to the patient.

Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC.

METHODS

A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion.

RESULTS

A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods.

DISCUSSION

This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.

Post-cholecystectomy acute injury: What can go wrong?

Backgrounds/Aims

Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries.

Methods

We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management.

Results

Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy.

Conclusions

Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Experimental comparison of abdominal drainage systems

BACKGROUND

In an experimental study the performance of different closed abdominal drainage systems was tested.

METHODS

A vacuum bottle designed for Redon Drainage, a flexible plastic bulb designed for Jackson-Pratt drains and a V.A.C.^® Negative Pressure Wound Therapy System were used. In a porcine cadaveric study mimicking the abdominal cavity the intrinsic pressure (IP) at one and three minutes (T0, T3) and the amount of evacuated fluid were measured.

RESULTS

The Redon and Jackson drainage displayed a rapid decline to IP values of almost zero comparing T0 and T3. Only the V.A.C.^® system was able to preserve constant values of negative IP values measured at both time points. Only the V.A.C.^® system was able to remove almost the whole amount of inserted fluid.

CONCLUSIONS

In an experimental setting the V.A.C.^® system was superior to the other two tested systems in delivering constant negative IP and the amount of evacuated fluid.