What are the guidelines for removing a laparotomy (surgical abdominal cavity) drain?

Guidelines for Laparotomy Drain Removal

Laparotomy drains should be removed as soon as possible after surgery when there is no evidence of ongoing fluid collection, with specific criteria based on drainage volume and characteristics.

General Principles for Drain Removal

• Routine prophylactic use of intra-abdominal surgical drains is discouraged in clean and clean-contaminated cases due to lack of evidence supporting their benefit 1
• Drains should be removed as soon as possible postoperatively to reduce drainage time and length of hospital stay 1
• Prophylactic subcutaneous drains after emergency laparotomy are not recommended as they provide no advantage in preventing postoperative wound infection 1

Specific Criteria for Drain Removal

Chest Drain Removal Criteria (Applicable to Abdominal Drains)

• Remove drains when air leaks are no longer observed and drain output has decreased to an acceptable level 1
• For abdominal drains, removal can be considered when:
  • Drainage is serous (non-purulent, non-chylous) 1
  • Daily output has decreased to less than 300-500 mL/day 1

Volume-Based Removal Criteria

• Evidence suggests that drain removal is safe when fluid drainage is less than 300 mL/24h compared to waiting for drainage less than 100 mL/24h 1
• Early drain removal (when output is <300-500 mL/day) is associated with:
  • Reduced pain scores 1
  • Decreased analgesic consumption 1
  • Shorter drainage time 1
  • Reduced length of hospital stay 1

Special Considerations

• In contaminated and dirty incisions with purulent contamination, delayed closure of surgical wounds may be considered instead of primary closure 1
• When delayed closure is performed, surgical revision is recommended between two and five days postoperatively 1
• For specific operations such as pancreatic surgery, drains may still be necessary 2
• Drain removal timing should not be based solely on postoperative day, as this is a poor indicator for appropriate removal 3

Potential Complications of Prolonged Drainage

• Retrograde contamination leading to infection 2
• Peritoneal irritation causing excess ascites formation 2
• Increased pain 2
• Longer hospitalization 1, 4
• Increased risk of surgical site infections 1

Algorithm for Drain Removal Decision-Making

1. Assess drain output volume daily:

   • If <300-500 mL/day of serous fluid → Consider removal 1
   • If >500 mL/day → Continue monitoring 1

2. Evaluate fluid characteristics:

   • Clear, serous fluid → Proceed with removal assessment 1
   • Purulent, bilious, or enteric content → Continue drainage and investigate possible complications 1, 5

3. Consider imaging if concerned about residual collections before drain removal 5

4. For drains placed for abscesses or fistulas:

   • Resolution of signs of infection 5
   • Decreased output to <10-20 cc/day 5
   • Radiographic resolution on follow-up imaging 5

Common Pitfalls to Avoid

• Removing drains too early in cases of pancreatic surgery or emergency surgery with high contamination risk 2
• Keeping drains in place too long, which may lead to retrograde infection 2
• Relying solely on arbitrary postoperative day for drain removal decisions 3
• Failure to recognize that drains may become occluded or positioned away from the intended collection site 2