What is the appropriate evaluation and management of green drainage from a Jackson‑Pratt drain after a ventral/incisional hernia repair?

Evaluation and Management of Green Drainage from Jackson-Pratt Drains After Ventral Hernia Repair

Immediate Diagnostic Priority: Rule Out Bile Leak or Enteric Fistula

Green drainage from a JP drain after ventral hernia repair most likely represents either a bile leak or an enteric fistula, and you must immediately obtain a JP drain fluid-to-serum bilirubin ratio to differentiate these from benign postoperative fluid. 1

Critical Diagnostic Algorithm

Step 1: Obtain JP drain fluid bilirubin level and simultaneous serum bilirubin

• A JP drain fluid-to-serum bilirubin ratio >5 is 100% sensitive and specific for bile leak 1
• If ratio >5: proceed directly to ERCP without delay 1
• If ratio <5: consider enteric fistula, particularly if green/bilious appearance persists 2

Step 2: Assess for systemic signs of complication

• Tachycardia ≥110 bpm is the earliest warning sign of intra-abdominal complications and mandates urgent evaluation 2
• Fever ≥38°C combined with tachycardia indicates possible deep infection or abscess requiring immediate surgical consultation 2
• Elevated lactate, CPK, or D-dimer suggest bowel compromise 2

Step 3: Obtain contrast-enhanced CT if enteric fistula suspected

• Look for discontinuity in bowel anastomosis or mesh-related complications 2
• Identify any undrained fluid collections requiring percutaneous drainage 2

Management Based on Etiology

If Bile Leak Confirmed (Ratio >5)

Immediate ERCP with therapeutic intervention 1

• Place biliary stent to divert flow and reduce pressure 2
• Ensure adequate external drainage via existing JP drain 2
• Consider percutaneous drainage of any biliary collections 2

If Enteric Fistula Suspected (Green Drainage, Ratio <5)

Early fistula (<6 weeks from surgery):

• Ensure adequate external drainage via JP drain 2
• NPO status with total parenteral nutrition 2
• Consider endoscopic stent placement across leak site if identified 2
• Address any downstream obstruction causing high intraluminal pressure 2

Chronic fistula (>6 weeks):

• Internal drainage strategy is superior to closure attempts 2
• Place double pigtail stents through fistula tract or perform septotomy 2
• Aggressive lavage of collections every 4-6 hours via percutaneous drain 2
• Multiple endoscopic interventions may be required 2

If Benign Postoperative Fluid (Ratio <5, Resolving Volume)

Conservative management with close monitoring:

• Continue JP drain until output <30 mL/day 2
• Monitor for signs of infection (fever, increasing WBC, purulent drainage) 2
• Remove drain once output criteria met 2

Critical Pitfalls to Avoid

Do not dismiss isolated tachycardia – it may be the only early sign of serious complications including bowel obstruction from the drain itself 2, 3

Do not rely on fluid color alone – there is overlap in color between bile leaks and benign drainage; the bilirubin ratio is definitive 1

Do not delay ERCP if bile leak confirmed – early intervention prevents progression to biliary peritonitis 1

Recognize drain-related bowel obstruction – JP drains can cause mechanical small bowel obstruction by creating a fulcrum around which bowel loops twist 3

Address downstream obstruction – failure to relieve distal stenosis or stricture will cause persistent leak regardless of local management 2

Indications for Urgent Surgical Consultation

• Tachycardia ≥110 bpm with or without other vital sign abnormalities 2
• Fever ≥38°C combined with tachycardia 2
• Signs of peritonitis on examination 2
• Increasing drain output or new onset of bilious/enteric drainage 2
• Failure of conservative management after 48-72 hours 2
• Evidence of bowel obstruction (distension, obstipation, vomiting) 3

Role of Prophylactic Drainage in Context

The evidence does not support routine prophylactic JP drain placement after clean ventral hernia repair 4. When drains are placed in contaminated fields (CDC Class II-III), they should be removed as soon as output criteria are met to minimize complications including infection and mechanical bowel obstruction 2, 3, 4.