Thursday, September 17, 2009

Historical Surgical Drains

Today, I’d like to share the section on surgical drains from the old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I first mentioned on Monday.

Glass and Metal Drainage Tubes

The use of rigid tubes for drainage is not now so general as it was at one time. Glass tubes are easily cleaned both inside and outside, and it is easy to see whether they are clean or not; but owing to their rigidity, they are apt to cause pain, so that their field is a restricted one. There are instances in which it is important to use a tube which will not collapse, and then a glass, or hard rubber, or metal tube is employed; but the ordinary purposes of drainage are accomplished just as well by the use of a flexible rubber tube, or one of the still more flexible gauze drains. Glass drainage tubes cost from ten to forty cents each, according to their shape and size.

 

Soft Rubber Drainage Tubes

Rubber tubing of various calibers forms a satisfactory material for drainage. Such tubing costs from seven to twenty cents a foot, according to the size and quality. The drainage tube can be prepared from a piece of tubing as follows: A piece of tubing of the required size, and having a smooth surface, is selected and cut to the required length. The end which enter the body is cut obliquely, and its sharp edge trimmed away with a pair of scissors. With a pair of curved scissors two or more oval openings are cut in the sides of the tube, beginning near its inner end, so as to permit the escape of pus in case the end of the tube is obstructed by contact with the tissues. The long axis of these openings is made parallel to the long axis of the tube, so that the tube shall not be unnecessarily weakened. A little practice will enable one to cut these openings neatly; or if one is very particular, then they may be burned out with a Paquelin cautery. This gives an opening with a smooth rounds edge, like the opening of a velvet eye catheter. (photo of Paquelin cautery – credit)

Catheters make excellent drainage tubes. Additional holes should be cut in them if necessary. The rounded tip may be left or removed, according to circumstances. If it is allowed to remain, insertion of the drainage tube is thereby facilitated.

In draining large wounds, and especially if irrigation is to be employed, two tubes should be used and fastened together at the top by a safety pin. This insures freer drainage and allows the irrigating fluid to flow into one tube and out of the other.

 

Gutta-percha Drains

Gutta-percha tissue is an excellent drainage material, especially for fresh wounds. It is employed in two ways: A piece of tissue, an inch or two wide, is folded upon itself until it makes a strip a half inch wide, more or less. Such a flat strip occupying very little space in a wound, and not adhering to the tissues, scarcely disturbs the aseptic healing of a wound. It is frequently inserted between the sutures of a wound at the close of operation in order to facilitate the escape of blood and serum. Moreover, if the operator is not sure of his asepsis, a drain of this character will allow the escape of any pus which may form, and prevent its burrowing in the deeper tissues. Two days after operation the wound should be re-dressed. If its appearance is satisfactory, the rubber tissue drain is removed, and the wound is allowed to unite primarily. If there is a seropurulent or purulent discharge the surgeon may decide to allow the drain to remain in place longer, or he may think it better to remove some of the sutures and introduce larger drains.

 

Cigarette Drains

Gutta-percha alone gives a flat drain; combined with gauze it forms a found or oval drain. This is know as a cigarette drain. A roll of gauze of the required size is wrapped with rubber tissue, as the tobacco in a cigarette is wrapped with paper. hence the name “cigarette” drain. The gauze should project slightly from the lower end of the drain, and should not be too tightly rolled. If the gutta-percha tissue shows a tendency to unwind, its edge may be stuck down with chloroform. Drains of this character are often employed in deeper wounds, for the same reasons that a flat gutta-perch drain is employed in shallow wounds; for example, after appendectomy, when there is a possibility that suppuration may form in the deeper tissues. Such a drain can be easily removed, since the only portion which can become adherent is the gauze at its lower end. For this reason the gauze should not project far beyond the gutta-percha tissue.

When gutta-percha tissue grows old it becomes brittle; hence it should be tested before it is used as a drain, lest a portion of the drain break off and remain in the wound. The tissue can be cut with scissors or torn. It has a distinct grain, so that in tearing it in one direction the motion should be quick; while in tearing it in the other direction, one must tear it very slowly in order to follow a straight line.

A finger from a rubber glove, or a finger cot from which the tip has been cut away, makes an excellent casing for a cigarette drain.

 

Gauze Drains

Gauze is often used for drainage, either plain or impregnated with different chemicals. Its chief disadvantage is the fact that it adheres so closely to the surface of the wound. These adhesions give way in five days to a week, but by that time granulations may already have grown into the meshes of the gauze. In spite of this drawback, gauze is used for drainage far more than any other material, both because it is always at hand, and because it is so flexible. It is not, however a good thing to use in the case of a sensitive patient on account of the pain caused by its removal. The most favorable time for the removal of a gauze drain is five or seven days after its insertion in a fresh wound.

The gauze drain may be of any size. A flat drain is formed by folding in the edges of a strip of gauze so that no loose threads appear. The two ends of the strip are then brought together, and the fold is inserted into the wound. This method facilitates the insertion of the drain, and also prevents loose threads from remaining in the wound when the drain is withdrawn.

A roll of gauze may be covered with gutta-percha tissue, making a cigarette drain. In this manner adhesions between the gauze and the surface of the wound are effectually prevented, and the drain can be easily removed at any time.

 

A Handkerchief Drain

If the wound is a a large one, and it is desired to keep it distended with a large quantity of gauze, adhesions may be reduced to a minimum by adopting the so-called Mikulicz method. This is also called a handkerchief drain. A single layer of gauze like a handkerchief is spread over the surface of the wound, and poked into all the recesses into which it is desired to carry the drains. Large flat gauze drains made in the manner above described are then carried into the different portions of the wound. The handkerchief limits adhesions between these central drains and the wound, so that they can be removed without much difficulty at any time. When they have been removed, the handkerchief itself being only a single layer, can be peeled off from the surface of the wound to which it is adherent.

 

Horsehair Drains

Small drains may be made of threads or horsehairs, by tying a number of them together, twisting the bundle, doubling it on itself, and allowing it to twist backward. Drains of this character are especially serviceable in scalp wounds, on account of the ease with which they can be inserted between the stitches.

 

 

Bookmark and Share

3 comments:

heri_md said...

thanks doc,...i'm treating a patient now, with skin laceration on her left leg.but, i find some problems,it seems that there are infection around the suture,i decide to re-suturing again and put a drain.the skin laceration length is about 15 cm.i put a handscoon drain.what do you think about it?how to manage the infection,because i only have amoxicillin and metronidazole,are they enough for the infection?

rlbates said...

I'm not sure what a handscoon drain is, but it seems to me that recleaning the wound, placing a drain, and adding antibiotics is a good thing. I did find a link that mentions a handscoon drain that may help you. I can't read it (it's not in English), but it looks informative (the photos, etc).

heri_md said...

once again,thanks,...it's indonesian language..and i'm from indonesia too.we usually use a handscoon drain, it's a hand gloves,usually from rubber or latex,we cut and use as a drain in small surgery like abses incision.it's quiet simple...i life in small village,and it's difficult to get some medicines.nice to see you