M. Sajjad Dar ( East Surgical Unit, Department of Surgery, King Edward Medical College, Mayo Hospital, Lahore. )
Abdul Mannan Babar ( East Surgical Unit, Department of Surgery, King Edward Medical College, Mayo Hospital, Lahore. )
Thirty patients underwent cholecystectomy without drainage, and 16 matched controls cholecystectomy with drainage. The wound infection rate was lower, hospital stay shorter and overall complication rate less in undrained patients. This study suggests that surgical drainage after uncomplicated cholecystectomy is unnecessary and may be unwise (JPMA 41:6, 1991).
In 1913, 31 years after Langenbuch1 performed the first cholecystectomy, Spivak2 introduced the technique of undrained ideal cholecystectomy. Since then many investigators have advocated omission of drainage after cholecystectomy under certain circumstances3-11. These reports describe a lower incidence of post operative morbidity, decreased hospital stay, easier convalescence and less discomfort. However most surgeons currently continue to drain the gall bladder bed. This study was designed to determine whether surgical drainage after simple cholecystectomy is necessary or not.
PATIENTS AND METHOD
From December 1987 to November 1989, 52 cholecystectomies were performed. Initially 32 operations were performed at Lahore General Hospital, while later 20 patients were operated upon at Mayo Hospital, Lahore. Only those cases were included in study who fulfilled the following criteria at surgery.
1) Absence of empyema or other evidence of gross infection.
2) A relatively dry gall bladder bed at the end of operation.
3) Elective operations that did not include exploration of common bile duct.
Of 52 patients, 6 did not fulfill the above criteria (all of them required common bile duct exploration) and were therefore excluded from the study. Of the remaining 46 patients, 44 were females and 2 males. Their ages ranged from 18 to 60 years. Thirty patients underwent cholecystectomy without drainage and 16 with drainage. Cholecystectomy was performed under general anaesthesia through a Kocher’s subcostal or Mayo-Robson incision. If drainage was provided, it was done through a separate stab wound using a tube drain in the gallbladder bed. It was attached to a closed drainage bag without suction. Antibiotics were used routinely perioperatively.
The accompanying table shows the frequency of post-operative complications. No death occurred in either group. Wound infection occurred in 12.5% patients with drains, and in none of the patients without drain, including 2 with incidental appendicectomy. None of the patients with wound infection had any associated risk factor like obesity or diabetes. Haemorrhage from drain wound occurred in one patient which needed re-exploration. There was no case of bile peritonitis or abscess nor anycase of Waltmann Walter’s syndrome. Considering all post-operative complications as a single. category, the group with drainage had a greater frequency of post-operative complications (18.7%) than did the group without drainage (0%). Post-operative hospitalization in patients without drainage ranged from 3-9 days with a median of 6 days, while in those with drainage it ranged from 6-17 days with a median of 9 days, One patient in drainage group who had a haemorrhage from drain site had the longest hospital stay (17 days).
A large number of surgeons continue to use drainage in all patients undergoing cholecystectomy. This practice is based on tradition rather than any scientific fact4,12. Mostly drains are employed in patients with acute cholecystitis, empyema, gangrene or perforation of the gall bladder; abscess formation, common bile duct exploration, incomplete haemostasis, evidence of bile leakage, and non-closure of gall bladder bed13. Results of this study are similar to other reports5,11,12, demonstrating more frequent wound infection in patients with intraperitoneal drains because drain being a foreign body allows the bacteria to gain access to the gall bladder bed or the abdominal walls and dressing made wet by drain discharges predisposes to bacterial contamination. The median post-operative hospital stay of our patients without drainage was 3 days shorter than that of those with drainage. Similar results are reported by others4,5,11. Patients were discharged on thebasis of clinical assessment; therefore we believe that a shorter hospitalization of patients without drainage represents an unbiased judgement of a better hospital course. The major reason for drainage of the subhepatic space after cholecystectomy is the fear of bile leakage that may lead to bile peritonitis or Waltmann Walter’s syndrome14. However many cases have been reported where surgical drain failed to prevent bile peritonitis or pericholecystic abscess11,15-18. The belief that surgical drains serve as an early warning of bile leakage, impending bile peritonitis, or intra-abdominal haemorrhage is also disputed11,15,18. . Many cases have been reported where bile peritonitis occurred without warning hours to weeks after cholecystectomy with drainage11,16,17. Therefore the lack of bile leakage from a drain cannot be interpreted as the absence of bile leakage or impending bile peritonitis15 as according to Frederick Coller “bile is not educated to climb drains"19. Sometimes drain may knot within the peritoneal cavity and these patients may require reexploration. Cholecystectomy without drainage has a similar mortality, and a decreased morbidity3-11. Results of neither this study nor others contradict the use of drains in the presence of bacterial sepsis or gross bile leakage. However we believe that in uncomplicated cases with a dry gall bladder bed, drainage is unnecessary.
1. Langenbuch, C. Ein Fall Von Extirpation der Gallenbiase Chronischer Cholelithiasis. Heilung. Berl Kim Wochenschr., 1882; 19:725.
2. Spivak, J.L. The surgical techniques of abdominal operations. 5th ed. Springfield, Illinois, Thomas, 1955, p. 618.
3. Dreese, W.C. Cholecystectomy without drains. J. Int. Coil. Surg., 1963; 40: 433.
4. Kambouris, A.A., Carpenter, W.S. and Allaben, R.D. Cholecystectomy without drainage. Surg. Gynaecol. Obstet., 1973; 137:613.
5. Goldberg, LM., Goldberg, J.P., Liechty, R.D., Buerk, C., Eiseman, B. and Norton, L. Cholecystectomy with and without surgical drainage. Am. J. Surg., 1975; 130:29.
6. Stone, H.H., Hooper, C.A. and Millikan, WJ. Jr. Abdominal drainage following appeendectomy and cholecystectomy. Ann. Surg., 1978; 187: 606.
7. Budd, D.C. Cochran, R.C. and Fouty, W.J.Jr. Cholecystectomywith and without drainage. A randomized, prospectve study of 300 patients. Am. J. Surg., 1982; 143:307.
8. Johnson, G. and Gilsdorf, R Routine versus selective drainage of the gall bladder bed after cholecystectomy. Am. J. Sung., 1981; 142:651.
9. Mittelman, J.S. and Doberneck, R.C. Drains and antibiotics perioperatively for elective cholecystectomy. Surg. Gynaecol. Obstet., 1982; 155:653.
10. Trowbridge, P.E. A randomized studyof cholecystectomy with and without drainage. Sung. Gynaecol. Obstet., 1982; 155: 171.
11. Williams,, C.B., Halpin, D.S. and Knox, J. S. Drainnage following cholecystectomy. Br. J. Surg., 1972; 59:293.
12. Nora, P.F., Vanecko, R.M. and Bransfield, Ji. prophylactic abdominal drains. Arch. Surg., 1972; 105:173.
13. Hoffmann, J. and Lorentzen, H. Drainage after cholecystectomy. BrJ. Surg., 1985; 72:423.
14. Strohl, E.L., Diffenbaugh, W.G. and Anderson, RE. The role of drainage following biliaiy tract surgely. Sung. Clin. North Am., 1964; 44: 281.
15. MacVicar, F.T., McNair, TJ., Wilken, BJ. and Bruce, J. death followinggall bladder surgery. J.R. Coil. Surg. Edinb., 1967; 12:139.
16. Douglas, D.M. and Grey Turner G. Bile peritonitis. Br. Med. J., 1940; 2: 280.
17. James, K.L Bile peritonitis of unusual causation. Lancet, 1938;2:311.
18. Mears, R.L. Bile peritonitis. Am. Surg., 1964; 30:583.
19. HoIm, J.C., Edmunds, L.H. and Baker, J.W. Lifethreatening com plications after operations on biliary tract. Surg. Gynaecol. Obstet., 1968; 127:241.