Author
Information
Dwivedi JS*,
Gupta AS
(*
First Year Resident, ** Professor. Department
of Obstetrics and Gynecology, Seth G. S. Medical College & K.E.M.
Hospital , Mumbai , India
Abstract
Surgical
drains are of different types - open and closed type, active and passive
drains. Corrugated rubber tubes
are examples of open drains. They can increase the
chances of infection. Closed drains remain sterile and are hence preferred by most
surgeons.
Active drains are maintained under suction pressure -high or low.[1] Various
types of drains are available in the market that are costly, especially for
poor patients. An economical suction vacuum drain can be easily assembled using
few basic things which are easily available in a hospital setting. One such
drain design to be placed in the subcutaneous tissues
in the anterior abdominal wall after laparotomy is being presented.
The
materials required are:
1.
One 20 ml syringe
2.
Two 10 ml syringes
3.
One 16 Fr Ryles' tube
4.
A small piece of adhesive bandage.
Steps To Make A Drain
& Its Simultaneous Insertion
1.
Using a No. 11 surgical blade mounted on
a Bard Parker handle, a small incision is made at the site where the drain is
to be inserted.
2.
Ryles tube no.16 Fr is passed through the
small incision and its perforations are placed in the subcutaneous tissue. The
Ryles' tube is fixed with a linen suture at its point of exit. A hemostat is
used to clamp the drain as seen in Figure 1.
Figure 1. Ryles tube clamped with an hemostat.
3.
The hub of the drain is connected to the
20 ml syringe. Suction is created by pulling the piston of the syringe against
the clamped Ryles' tube as seen in Figure
2
Figure 2. Creating the Vacuum in the syringe.
4.
The pistons of two 10 ml syringes are now placed
on either side of the central piston of the 20 ml syringe as seen in Figure 3.
The two pistons are placed in such a way on the flange of the 20 ml syringe so
that the upper end of one piston and the lower end of the other piston rests on
the flange.
Figure 3. Placement of the two lateral supports of the central piston.
Yellow arrows have marked the Flange. Pink line marks the lower circle of the
piston (20 ml syringe) & the pink arrows show where the lower end of the 10
ml syringe piston rests.
5.
All the 3 pistons are now supported and a
piece of adhesive bandage is used to bind them to each other as seen in Figure
4.
Figure 4: Bound pistons to maintain the vacuum.
Figure 5: Assembled Syringe Suction Vacuum Drain
6.
Now the haemostat on the Ryles tube which
is inserted as mentioned in point 1is released so that the vacuum in the
syringe is now continuous with the subcutaneous tissue fluid.
This
entire assembly is the design of an easy to assemble, affordable, syringe
suction vacuum subcutaneous drain. The drain needs to be charged whenever 10 ml
output accumulates in the 20 ml syringe. This drain can be easily dismantled
and reinstalled after recreating the vacuum.
Charging the drain
(Recreating the vacuum)
1.
The Ryles tube is clamped with a hemostat,
the 20 ml syringe is disconnected from it and the hub of Ryles tube is closed.
2.
The adhesive tape is
removed.
3.
The sero-sanguineous fluid collected
in
the syringe is properly discarded.
4.
The Ryle’s tube is reconnected to the hub
of the emptied 20 ml syringe and the syringe
suction drain
is assembled as before.
Discussion
Surgical sites can have potential dead spaces. These become reservoirs
for collection of body fluids. Such collections are best prevented so as to reduce
the chances of seroma formation, wound infections and wound disruption. Closed
drainage systems are used to drain such potential spaces. Drains available in
the market add to the cost of the procedure. Simple designs that are easy to
assemble in the operation theatres are documented in literature. Syringes have
been used in these designs to create low cost closed drainage systems not only
in surgeries on human beings but also in veterinary medicine.[2,3,4]
In our drain design we have used two pistons of a 10 ml syringe. The height of
these pistons and the inverse direction placement of the two pistons is such
that it not only rests snugly on the flange of the 20 ml syringe but also on
the edge of the lower circle of the piston of the 20 ml syringe. This is
further reinforced by binding all the three pistons with an adhesive tape
making it very stable. We used 16 Fr Ryle's tube as the perforations are
already present, it is freely available in the operation theaters, and it has a
wide bore to adequately drain out fluid containing blood. It does not get
easily blocked with small blood clots. The negative pressure generated was
measured with a manometer and it is - 600 mm of Hg. Venkatachalapathy's[1]
syringe drain wherein the needle
cap is used in the groove of the piston may be adequate for small capacity
syringes but the length of the needle cap will fall short when larger capacity
(longer) syringes are used and the piston of the syringe will then sit
obliquely in the syringe after using the needle cap in the piston groove. They
also recommended infant feeding tube or scalp vein cannula[1,4] as drain tubes. In our opinion this can get
blocked as the inner diameter of these tubes will be quite narrow. Besides, perforations have to be
made in these tubes and this may weaken
the tube and while removing, the tube may get fractured and a piece can get
retained in the wound requiring surgical incision and extraction. Ryles tube
has pre-formed stable perforations and thus has less chance of fracturing in
the wound. The steel spring recommended by Singh is not available in the operation theatre and
has to be specially procured.[4] The design by Ellur requires
the use of sharp instruments to bore a hole in the piston with a needle as well
as with a towel clip.[3] None of these drains documented in literature
have measured or mentioned the negative suction pressure that is created
by their designs. [2,3,4,5] We would like to highlight certain
features of these suction drains.
Design
|
Cost
|
Maneuverability
|
Negative Pressure
|
Drain Tubing sizes
|
Ours
|
Rs. 13/-
|
Easy and stable
|
-600 mm of Hg
|
Large (16 Fr Ryles' tube)
|
Venkatachalapathy's[1]
|
Not stated
|
Easily but unstable
|
Not studied
|
Small (infant feeding tube or scalp vein cannula)
|
Ellur[3]
|
Not stated
|
Chances of injury while assembly due to use of
sharps
|
Not studied
|
Small (8 No. infant feeding tube)
|
Singh[4]
|
Not stated
|
Steel spring not an item available in the operation
theatre.
|
Not studied
|
Small ( scalp vein cannula)
|
Marketed Drains: Mini
|
Rs.120/-
|
Bulky
|
-100 to:-150 mm of Hg [5]
|
|
Marketed Drains: Standard
|
Rs.
261/-
|
Bulkier
|
-300 to -500 mm of Hg [5]
|
Our drain is recommended for use only in the subcutaneous tissues and
not intra peritoneally due to the high negative suction pressure that is
created.
Conclusion
Our syringe drain design is superior as it is not only simple to
assemble from easily available material but is also easy to use,
is very stable, does not use any sharps and it provides adequate
suction pressure to drain the subcutaneous tissue.
It uses a wide drain tube which is less likely to get blocked. The cost
price of our drain is also only Rs. 13/- that is
9
times less than that of the marketed Mini suction drain. This drain is highly
recommended for its design, material used and for its low cost in low resource
health care systems and societies.
References
1.
Rock, JA., Jones, H W.
Incisions for Gynecologic Surgery. In Rock JA, Jones HW III, editors. Te
Linde’s Operative Gynecology.10th ed. New
Delhi
2.
Venkatachalapathy TS,
Nagendra Babu T, Sreeramulu PN (2012) A Simple Syringe Suction Drain for
Surgical Procedures. J Clin Case Rep 2012;2:216.
3.
Ellur S. Syringe suction
drain further simplified. Indian J Plast Surg 2007;40:107-9.
4.
Singh A, Singh G (2003)
Syringe suction drain-II. Br J Plast Surg 56: 313.
5.
Jain, SK, Stoker,
DL, Tanwar, R Basic Surgical Skills and
Techniques: Drains in Surgery, JP
Medical Ltd, 2013 -pg 72-73.
Citation
Dwivedi JS,
Gupta AS.