Closed suction wound drainage and lower-segment caesarean section

In a randomized controlled study of wound suction drainage after transverse suprapubic incision for lower-segment caesarean section no significant advantages could be demonstrated for routine drainage in terms of wound infection, haematoma formation, duration of hospital stay or analgesic requirements.     

Postmastectomy seromas and wound drainage

Wound seromas and lymphedema are continuing problems after mastectomy for carcinoma of the breast. This study was done to determine whether or not the volume of postoperative wound drainage was related to the frequency of seromas and lymphedema of the arm. The daily wound drainage and the total hospital drainage (THD) were recorded for 49 consecutive patients who had undergone a mastectomy and the results were correlated with the frequency of seromas and lymphedema. All of the patients had modified mastectomies and no irradiation. All had closed suction drainage and none had flap necrosis or infection. Suction catheters were discontinued three to 15 days after operation at the discretion of the surgeon. THD varied from 227 to 3,607 milliliters and did not correlate with body weight. Twenty-six patients had wound seromas develop requiring drainage for up to seven months, most often with repeated aspirations, but in four instances ultimately with open drainage. THD and 24 hour drainage immediately prior to discontinuing suction catheters correlated directly with the frequency of seroma formation. No patient with less than 20 centimeters of drainage in the 24 hours prior to catheter removal had a seroma. Ipsilateral edema of the arm (more than 3 centimeters difference in circumference) developed in five patients. THD was directly correlated with the frequency of edema of the arm. No patient with less than 500 milliliters of THD had edema develop whereas the frequency rate was 75 per cent with THD of more than 900 milliliters. It was concluded that THD likely reflects the magnitude of lymphatic interruption after mastectomy and, consequently, the likelihood of lymphatic insufficiency and lymphedema. Minimal wound drainage of 24 hours before discontinuing closed drainage catheters minimized seroma formation.     

Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery--a metaanalysis

A systematic literature review and meta-analysis of published data evaluating the effectiveness of prophylactic subcutaneous drainage to prevent wound complications in women undergoing cesarean delivery was performed. We identified 6 randomized trials of prophylactic subcutaneous drainage after cesarean delivery. Meta-analysis was performed and Peto odds ratios were calculated for each study outcome. The use of prophylactic subcutaneous drainage was not associated with a reduction in the rate of wound disruption (odds ratio 0.74, 95% CI: 0.39-1.42, P = .36, infection (odds ratio 1.15, 95% CI: 0.70-1.90, P = .58), hematoma (odds ratio 1.05, 95% CI: 0.33-3.30, P = .94), or seroma (odds ratio 0.44, 95% CI: 0.14-1.43, P = .17) when compared with women who were not receiving subcutaneous drainage. Prophylactic use of subcutaneous drainage does not prevent significant wound complications after cesarean delivery.     

A new and quick method for treating postmastectomy seromas.

The Seroma-Cath wound drainage system has proved to be a quick and effective method for treating postmastectomy seromas. It has been well received by the patients we studied, has eliminated frequent office visits, bulky dressings and the risk of wound infections.     

Subcutaneous drainage versus no drainage after minilaparotomy in gynecologic benign conditions: a randomized study

OBJECTIVE: The purpose of this study was to determine the outcomes of subcutaneous drainage in patients who are affected by benign gynecologic diseases that are treated by a Kustner's minilaparotomy incision. STUDY DESIGN: We performed a randomized controlled study with 72 patients who underwent operation for benign gynecologic disease. Patients were assigned intraoperatively to two groups: group A (36 patients) had a closed drainage system and group B (36 patients) had no drainage. Historic data, clinical and surgical characteristics, and perioperative complications were recorded prospectively. Postoperative care data, surgical incision complications, and hospital stay were analyzed. Patients were to be seen 4 weeks after the operation to assess wound healing. RESULTS: No patients had intraoperative complications or blood transfusions. A significant difference was observed between the drainage versus no-drainage groups regarding postoperative complications and hospital stay (P =.001, both groups). No patients had surgical complications at 4 weeks after the last operation. CONCLUSION: Our data suggest that routine prophylactic subcutaneous drainage is indicated in patients who undergo Kustner's minilaparotomy incision for benign gynecologic operation. Drains significantly prevent wound complications and reduce hospital stay.     

A Controlled Trial on Wound Drainage in Caesarean Section

A randomized controlled trial was carried out to investigate the influence of drainage on wound infection following Caesarean section. The incidence of clinical wound infection was significantly reduced if a Redivac suction drain was placed beneath the rectus sheath. Subcutaneous corrugated drains were found to offer no advantage. Three different degrees of postoperative pyrexia are examined for their predictive value for the development of wound sepsis. The influence of duration of amnion rupture and the number of vaginal examinations in labour on the postoperative incidence of wound infection and pyrexia are examined.     

Postoperative wound infection with Pasteurella multocida from a pet cat

We summarize an unusual postoperative wound infection that was caused by Pasteurella multocida from a house cat licking the incision in an obese gynecologic oncology patient. A 48-year-old morbidly obese woman had a wound abscess 6 weeks after hysterectomy and panniculectomy for a International Federation of Gynecology and Obstetrics stage IA grade 1 endometrial cancer. P multocida was cultured from the abscess and the patient was treated with drainage and intravenous antibiotics. Further history revealed that her house cat had licked the wound. P multocida wound infection is a potential complication for people with dog or cat contact postoperatively. Penicillin G is the antibiotic of choice for treatment.     

Use of highly evacuated Redon drains after gynecologic laparotomies

Highly evacuated (980 mbar) wound drainage systems according to Redon were used in 100 gynecologic laparotomies. In 96% of cases, no flask exchange was required before the system was removed. Bacteriological specimens from various locations of the Redon system showed minimal colonization with pathogenic bacteria. No correlation was found between secondary wound healing and bacterial findings in the system.     

Early secondary suture versus healing by second intention of incisional abscesses

A controlled trial was set up to compare the treatment of wound abscesses, occurring after laparotomy, with either early secondary suture combined with cefuroxime and metronidazole given intravenously or by healing by second intention. The secondary suture was performed two days after wound drainage and resulted in a significant reduction (p less than 0.01) in healing time without complications. No reinfections occurred.     

Subcutaneous drain vs. suture in obese women undergoing cesarean delivery. A prospective, randomized trial

OBJECTIVE: To determine if subcutaneous drain or closure of the subcutaneous layer decreases the incidence of wound complications in obese women undergoing cesarean delivery. STUDY DESIGN: Seventy-six obese women undergoing cesarean delivery and with at least 2 cm of subcutaneous fat were randomized to one of three groups: group 1 had suture closure of the subcutaneous tissue, group 2 had placement of a subcutaneous closed suction drain, and group 3 had neither suture closure nor drainage. RESULTS: Wound separation occurred in 12 (15.8%), seroma in 5 (6.6%) and infection in 3 (4%). There were no reports of wound hematoma. The overall incidence of any wound complication (infection, separation, seroma, hematoma) was higher in obese women who received neither subcutaneous suture nor drain as compared to obese women who received either subcutaneous suture closure or subcutaneous drain. The incidence of major wound complications (infection or separation) was also higher in obese women who received neither subcutaneous suture or drain compared to obese women who received either subcutaneous suture closure or subcutaneous drain. CONCLUSION: The use of closed suction drainage in the subcutaneous space may reduce the incidence of postoperative wound complications in obese women who have at least 2 cm of subcutaneous fat and undergo cesarean delivery.     

Value of subcutaneous drainage system in obese females undergoing cesarean section using pfannenstiel incision

OBJECTIVE: To determine whether closed subcutaneous drainage systems were efficacious in reducing the rate of wound breakdown of Pfannenstiel incision after cesarean section (CS) in obese females. DESIGN: Prospective controlled clinical trial. PARTICIPANTS: 118 obese pregnant females with a body mass index >32 undergoing CS were divided into two groups: group I (n = 78) with closed subcutaneous drainage system and group II (n = 40) without drainage system. Incision closure technique was standardized. Prophylactic antibiotics were given routinely to both groups. OUTCOME MEASURES: Primary outcomes were the incidence of wound breakdown in both groups together with rate of hematoma formation and occurrence of fever. Secondary outcomes were amount of fluid drained, need for redressing. RESULTS: Wound breakdown occurred in 9 cases in group I (11.5%), while it happened in 5 cases in group II (12.5%) (p > 0.05). Relative risk was 0.92 (95% CI 0.26-3.75). Hematoma formation was observed in only 1 case in the nondrainage group (group II). Fever was observed in 18 cases in group I (23.1%) in the first 24 h postoperative while in group II, 13 cases developed fever (32.5%) (p > 0.05). The need for redressing within the first 24 h was only in 2.5% of cases in group I while it was 17.9% in group II (p < 0.05). CONCLUSION: We found no significant benefit in using a subcutaneous drain as a prophylactic measure against wound breakdown in obese pregnant females undergoing CS as long as they received a prophylactic antibiotic.     

Rupture of a tuboovarian abscess into the anterior abdominal wall: a case report

BACKGROUND: Rupture of a tuboovarian abscess is a life-threatening emergency. The current standard of care is surgery to manage the onset of peritonitis and sepsis. CASE: A 34-year-old woman presented with gradually worsening abdominal pain over several weeks. She had fever, pelvic tenderness, an elevated white blood cell count and ultrasonographic evidence of a tuboovarian abscess. After 48 hours of triple antibiotic therapy without a clinical improvement, she underwent surgery, during which she was found to have an abscess that had ruptured into the abdominal wall. A supracervical hysterectomy/bilateral salpingo-oophorectomy and surgical debridement of the subcutaneous tissue was performed, with wet to dry dressing changes of the surgical wound. Over the following 18 months, the patient required extensive wound care for recurrent bouts of wound drainage. CONCLUSION: Rupture of a tuboovarian abscess usually presents with sudden worsening of the patient's condition. Delays in surgical debridement and drainage increase the rate of associated mortality. Atypical presentations may present as cases resistant to conventional medical therapy, with fewer of the associated risks of life-threatening peritonitis and subsequent sepsis. Our patient represents the first reported case of extraperitoneal spillage of abscess contents from rupture of a tuboovarian abscess into the anterior abdominal wall.     

Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial

OBJECTIVE: The purpose of this study was to compare a subcutaneous stitch closure and subcutaneous drain placement for the risk of wound disruption after cesarean delivery. STUDY DESIGN: This was a prospective randomized clinical trial that evaluated subcutaneous stitch closure, placement of a subcutaneous drain, or no closure for subsequent wound disruption risk in women with subcutaneous depth at >or=2 cm. RESULTS: The maternal demographics and intrapartum risk factors for postoperative wound disruptions were similar among the 964 study subjects, who were divided into 3 groups. Wound disruptions that required opening of the wound, irrigation, debridement, packing, and/or secondary delayed closure occurred in 9.7% of the women with no closure, 10.4% of the women in the stitch closure group, and 10.3% of the women in the closed drain group (P =.834). CONCLUSION: There appears to be no difference in the subsequent risk of wound complications when no closure of the subcutaneous tissue layers occurs versus suture closure or a closed drainage system.     

Mediastinal tap as useful method for the early diagnosis of mediastinal infection

The simple and quick technique of mediastinal aspiration (mediastinal tap) can facilitate the early diagnosis of mediastinitis in the postoperative cardiac surgical patient. This technique offers objective evidence of mediastinal infection before the development of wound drainage or sternal instability, or both.     

Incarcerated hernia in a 5-mm cannula wound

Laparoscopic suturing and repairing of the fascial opening at 10- to 12-mm cannula puncture sites is well established; however, closing a 5-mm cannula wound is not well documented. We often leave the wound open without suture and cover it with gauze after removing the surgical drainage tube. An unusual early postoperative complication of laparoscopic surgery was an incarcerated hernia in a 5-mm cannula site. The 9-year-old girl underwent laparoscopic surgery due to an 8-cm ovarian mature teratoma. After 7 days, she came to our hospital because of a protruding mass in the left cannula wound. The mass was excised, and incarcerated fallopian tube torsion with necrotic change was diagnosed.     

The use of Marlex mesh in patients with generalized peritonitis and multiple organ system failure

Patients with generalized peritonitis form a rather threatened group, with a high mortality and risk of complications which increases when multiple organ failure develops. In 20 patients with this condition, the laparotomy wound was closed without tension using a Marlex mesh prosthesis, after surgical treatment of the underlying illness and drainage of the abdominal cavity. The mortality was lower than expected, according to data from the literature; also, pulmonary complications, residual abscesses and wound dehiscence occurred less frequently. This method seems to be a valuable contribution to the complex treatment of these patients.     

Surgical wound drainage: a survey of practices among gynaecologists in the British Isles

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.     

Surgical wound drainage: a survey of practices among gynaecologists in the British Isles

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.     

“Medically Necessary” Panniculectomy to Facilitate Gynecologic Cancer Surgery in Morbidly Obese Patients

A retrospective review of patients in our practice who underwent abdominal panniculectomy to facilitate gynecologic cancer surgerywas performed. The objective of the study was to determine if pannicu-lectomy was a safe and useful procedure in the morbidly obese gyneco-logic cancer patient. A total of 12 patients underwent the procedure between 1992 and 1996. Optimal pelvic oncologic surgery was accom-plished in all 12 patients. All aspects of those procedures were per-formed by gynecologic oncologists. The Buchwalter retractor was usedin all cases. The patients' weights ranged from 170 to 429 pounds, with a mean of 275 pounds. The mean body mass index was 48, with a range from 37 to 67. Four patients had a history of diabetes mellitus. Nine patients healed without wound complications. Three patients developed superficial subcutaneous wound infections/necrosis that were successfully managed with office debridement. Abdominal panniculectomy is a reasonably safe procedure that makes radical pelvic surgery possible regardless of the patient's weight. Prolonged wound bulb suction drainage may decrease the incidence of wound necrosis/infection in these high-risk patients.     

Predictors of complications after inguinal lymphadenectomy

OBJECTIVE: The aim of this study was to identify predictors of complications in patients undergoing inguinal lymphadenectomy (LND) in the treatment of vulvar carcinoma. METHODS: Clinical information was abstracted from records of patients with invasive vulvar cancer. All patients underwent LND. Closed suction drains were placed in groin incisions and removed when output was less than 30 ml/24 h. Associations between variables were studied by chi(2) and t tests. RESULTS: Sixty-seven patients undergoing 112 LND were evaluated. Eighty-eight percent of patients underwent radical vulvar surgery and LND while 12% underwent LND alone. Patients were treated with either unilateral (22) or bilateral (45) LND. Seventy-three percent received extended postoperative prophylactic antibiotics. The median duration of suction drainage was 15 days for one drain and 14 days for two drains. Early postoperative cellulitis (<30 days after surgery) developed in 35.4%, early wound breakdown in 19.4%, early lymphedema in 4.8%, and early lymphocyst formation in 13.1%. Late cellulitis (>30 days after surgery) developed in 22.2%, late wound breakdown in 3.2%, late lymphedema in 29.5%, and late lymphocysts in 5%. Patients developing early cellulitis were more likely to have early wound breakdown (P = <0.001, RR 14.2) or early lymphocyst formation (P = 0.016, RR 7.6). Type of procedure, antibiotic use, need for adjuvant therapy, and duration of suction drainage did not influence early complications. Early complications and management strategies did not predict late complications. CONCLUSIONS: Chronic lymphedema occurs in nearly 30% of patients after LND. Late complications after LND were not predicted by early complications. New strategies for prevention of chronic lymphedema are needed.