After removal of a percutaneous drain, should the incision be packed to promote healing?

Wound Management After Percutaneous Drain Removal

Simply covering the incision site with a sterile dry dressing is recommended—packing is not necessary and causes more pain without improving healing.

Evidence-Based Recommendation

The most direct evidence comes from the 2014 IDSA guidelines for skin and soft tissue infections, which explicitly states that "one small study found that packing caused more pain and did not improve healing when compared to just covering the incision site with sterile gauze" 1. This recommendation prioritizes patient quality of life (reduced pain) without compromising wound healing outcomes.

Supporting Evidence from Multiple Clinical Contexts

Abscess Drainage Sites

The strongest recent evidence comes from the PPAC2 randomized controlled trial (2022), which enrolled 433 patients across 50 sites 2. This high-quality study demonstrated:

• Pain scores were significantly higher with packing (38.2 vs 28.2 on 100-point scale, p<0.0001)
• No difference in fistula formation (15% packed vs 11% non-packed, p=0.20)
• No difference in abscess recurrence (3% packed vs 6% non-packed, p=0.20)
• Patients used significantly more pain medications when packed

The 2021 WSES guidelines on anorectal emergencies concluded that "no recommendation can be made regarding the use of packing after drainage of an anorectal abscess" but noted that available evidence shows packing is "costly and painful and does not add benefit to the healing process" 3.

Surgical Incisions

The 2023 WSES emergency laparotomy guidelines recommend against routine subcutaneous drains after emergency procedures, noting they "do not confer any advantage in preventing postoperative wound infection" 4.

Clinical Algorithm

For percutaneous drain removal sites:

1. Remove the drain using standard technique
2. Apply a dry sterile dressing (gauze or similar)
3. Do NOT pack the tract
4. Change dressing daily until epithelialization begins
5. Monitor for signs of infection (erythema, purulent drainage, fever)

Key Caveats

• Exception for contaminated/dirty wounds: If there was purulent contamination or signs of active infection, consider delayed closure rather than packing 4
• Dead space management: If significant dead space exists, use quilting sutures rather than packing 4
• Antibiotics: Reserve for patients with systemic signs of infection, not routine use 1

Why Packing Fails

Multiple studies consistently show packing:

• Increases pain scores by 20-40% 2, 5
• Requires additional healthcare visits and costs 3
• Does not reduce recurrence or improve healing 6, 7, 8
• May actually increase anxiety, especially in pediatric patients 8

The theoretical benefits of preventing premature skin closure and maintaining hemostasis have not been borne out in clinical trials. Modern evidence supports that the body's natural healing process, combined with simple dry dressing coverage, is superior to traditional packing methods.