Drain Placement Sites in Gynecological Procedures
Drains should NOT be placed routinely in most gynecological procedures, as they do not reduce complications and increase infection risk; however, when indicated for specific procedures like inguinofemoral lymph node dissection, drains should be placed bilaterally in the groin dissection beds. 1
Evidence Against Routine Drainage
The American College of Obstetricians and Gynecologists explicitly recommends against routine prophylactic drainage in most gynecological procedures, as drains do not reduce complications and may increase infection risk and prolong hospital stay. 1 This represents a significant shift from historical practice where drains were used almost universally. 2
Key evidence demonstrates:
- Patients with drains have similar rates of mortality, morbidity, infections, and re-interventions compared to those without drains 1
- Drains increase surgical site infection rates and provide a conduit for bacterial entry 1
- Prolonged drainage beyond 24 hours significantly increases infection risk 1
- Drains delay hospital discharge without providing benefit in earlier detection of fluid collections 1
Specific Indications and Anatomical Sites
When Drains ARE Indicated:
Inguinofemoral Lymph Node Dissection (IFLN) for Vulvar Cancer:
- Placement site: Bilaterally in the groin dissection beds 1
- Duration: Remain until output is <30-50 cc per 24 hours (typically 5-7 days minimum) to prevent lymphocyst formation 1
- Type: Closed suction drains 1
Radical Vulvectomy with Lymphadenectomy:
- Placement site: Groin dissection beds 1
- Purpose: Manage expected fluid accumulation from extensive dissection 1
- Type: Closed suction drains 1
Deep Pelvic Collections (Therapeutic, Not Prophylactic):
When drainage is required for established fluid collections or abscesses, multiple anatomical routes are available 1:
- Transvaginal approach: Most sterile route for accessible pelvic collections (preferred by the American College of Radiology) 1
- Transabdominal approach: For collections not accessible vaginally 1
- Transgluteal approach: For specific anatomical considerations 1
- Transrectal approach: Alternative route for certain collections 1
- Transperineal approach: For specific anatomical locations 1
For tubo-ovarian abscesses in women of reproductive age, early drainage combined with medical management results in pregnancy rates of 32-63% compared to 4-15% with antibiotics alone. 1
Drain Management Principles When Used
Removal timing:
- Remove drains as soon as possible, ideally within 24 hours, to reduce infection risk 1
- For lymph node dissections, remove when output is <30-50 cc per 24 hours 1
- For other indications, remove when output is <300-500 mL per 24 hours with clinical improvement and serous fluid character 1
Monitoring requirements:
Procedures Where Drains Should NOT Be Used
Simple vaginal hysterectomy: Drains may be safely eliminated 1
Wide margin lumpectomies: Avoid routine drain placement unless axillary dissection is performed 3
Most benign gynecologic surgery: Few strong indications exist 2
Critical Pitfalls to Avoid
- Never leave drains longer than necessary: Each additional day beyond 24 hours significantly increases surgical site infection risk 1
- Do not use drains prophylactically: They do not prevent complications in routine procedures 1
- Avoid drains in contaminated cases without clear indication: Evidence for selective drainage in contaminated abdominal cases remains weak 1
- Consider saphenous vein preservation during IFLN dissection to reduce complications 1
Drain Types for Gynecological Use
When drains are indicated, closed suction systems (high-pressure vacuum drains) are preferred as they are efficient, allow easy monitoring, and provide safe disposal of drainage. 4 For complex fluid collections requiring therapeutic drainage, ported drains (multi-lumen catheters) are more effective and allow irrigation if needed. 1