Drains in Gynecological Procedures
Primary Recommendation
Routine prophylactic drainage should be avoided in most gynecological procedures, as drains do not reduce complications, may increase infection risk, and prolong hospital stay. 1, 2, 3
Indications for Drain Use
Strong Indications (Where Drains ARE Recommended)
Inguinofemoral lymph node dissection (IFLN) for vulvar cancer: Drains are routinely used and should remain until output is <30-50 cc per 24 hours (typically 5-7 days minimum) to prevent lymphocyst formation by allowing skin flaps to adhere to underlying tissue 1
Radical vulvectomy with lymphadenectomy: Closed suction drains are indicated to manage expected fluid accumulation from extensive dissection 1
Situations Where Drains Should NOT Be Used
Routine benign gynecological surgery: No evidence supports prophylactic drainage in clean or clean-contaminated cases 2, 3
Vaginal surgery: Vaginal packing does not decrease postoperative bleeding or hematoma formation, may increase infection rates when left >24 hours, and leads to longer catheterization with higher UTI rates 1
Pelvic reconstructive surgery: For low-risk procedures (periurethral bulking, suburethral slings), early ambulation alone is sufficient 1
After appendectomy for perforated appendicitis: Drains provide no benefit in preventing intra-abdominal abscess and prolong hospitalization 1, 2, 4
Controversial/Limited Evidence Scenarios
Subcutaneous drainage in minilaparotomy: One small randomized study (n=72) showed reduced wound complications and shorter hospital stay with subcutaneous closed drainage after Kustner's minilaparotomy for benign disease 5, but this contradicts broader evidence against routine drainage 2, 3
Contaminated abdominal cases: The situation may differ in heavily contaminated cases, though high-quality evidence is lacking 1
Types of Drains Used
Closed Suction Systems (Preferred)
Jackson-Pratt (JP) drains: Low-pressure vacuum drains that use gentle suction, easy for patients to manage, and allow for vacuum pressure reinstatement 6
High-pressure vacuum drains: Sealed, closed-circuit systems that are efficient, allow easy monitoring, and provide safe disposal of drainage 6
Closed suction drains for IFLN: Standard for inguinofemoral lymph node dissection, maintained until specific output criteria met 1
Specialized Drainage Systems
- Vacuum-assisted closure (VAC) dressings: Used occasionally for radically excised vulvar/perineal wounds, showing decreased healing time (44.4 vs 60.2 days, P=0.0175) and reduced rates of lymphocele, lymphorrhea, and lymphedema after inguinofemoral dissections 1
- Critical caveat: Contamination with stool/urine must be avoided; requires Foley catheters, antimotility agents, rectal tubes, or waterproof dressings 1
Open vs Closed Systems
- Closed systems are strongly preferred over open drains in all gynecological applications to minimize infection risk 7, 6
Anatomical Sites for Drain Placement
Inguinal Region
- Inguinofemoral lymph node dissection sites: Drains placed in groin dissection beds bilaterally when indicated 1
- Positioned to allow overlying skin flaps to adhere to underlying tissue 1
Pelvic Cavity
- Deep pelvic collections: Can be drained via multiple routes depending on location and operator preference 1:
- Transabdominal: Preferred for potentially sterile collections (most sterile route) 1
- Transgluteal: Through greater sciatic foramen, medial to sciatic nerves, below piriformis muscle to prevent persistent pain 1
- Transvaginal: Common in academic centers, useful for tubo-ovarian abscesses (TOA) where early drainage improves fertility outcomes (32-63% pregnancy rates vs 4-15% with medical management alone) 1
- Transrectal: More commonly used in academic centers 1
- Transperineal: Most common after low anterior resection for rectal cancer 1
Subcutaneous Space
- Subcutaneous drains: Limited evidence supports use in thick subcutaneous fat (>3.0 cm) in high-risk colorectal patients, where drainage reduced superficial SSI from 38.6% to 14.3% 2
Vulvar/Perineal Wounds
- Superficial wound drainage: VAC dressings applied directly to radically excised vulvar wounds 1
Drain Management Principles
Duration and Removal Criteria
IFLN drains: Continue until <30-50 cc per 24 hours, minimum 5-7 days 1
General abdominal drains (if placed): Remove when output <300-500 mL per 24 hours with clinical improvement and serous fluid character 8
Early removal preferred: Remove drains as soon as possible (ideally within 24 hours) to reduce infection risk 2
Monitoring Requirements
- Daily output measurement and fluid character assessment 8
- Clinical improvement indicators: resolution of fever, decreasing leukocytosis, improving systemic signs 8
- Imaging confirmation with CT if clinical improvement is equivocal 8
Critical Pitfalls to Avoid
Infection Risk
- Drains increase infection risk: They provide a conduit for bacterial entry and are associated with higher surgical site infection rates 1, 2, 4
- Prolonged drainage (>24 hours) significantly increases SSI risk 2
Delayed Discharge
- Drains delay hospital discharge without providing benefit in earlier detection of fluid collections 2, 4
- Mean mobilization, first flatus, and first oral intake times are longer with drains 3
Drain-Related Morbidity
- Substantial complications include fever, wound infections, peritoneal fluid accumulation, and wound dehiscence 1, 2, 4
Inappropriate Use
- Do not use drains routinely in clean/clean-contaminated gynecological cases 2, 3
- Do not rely on volume alone for removal—always assess clinical status and fluid character together 8
- Recognize when percutaneous drainage fails (multiloculated collections, viscous debris, fistulous communication) and transition to surgical management 8
Special Considerations
Oncological Surgery
- Drains placed significantly more frequently during oncological procedures 3
- Radical vulvar surgery with lymphadenectomy represents the strongest indication for drain use in gynecology 9