As Shakespeare once posited: “To drain or not to drain. That is this the question.”
Perhaps it wasn’t him.
Surgeon preference typically dictates whether a drain makes sense. Keeping a hematoma from forming means avoiding one additional nidus of infection. But, a drain (even a closed drain), can also serve as a nidus of infection. I know the pros and cons do not end there. But, I want to change direction.
I received a call from a plastic surgeon in the Northeast. He placed implants in a patient. He also placed a Jackson Pratt drain. He left town for a long weekend. His nurse, who had removed many Jackson Pratt drains, tried to remove this drain. Seemed a little stuck, but, with a little added pressure, only some of the drain came out. The rest never slid out. It was left embedded in the wound, adjacent to the implant. It’s unclear whether a stray suture caught the drain. Or whether the drain was kinked and fractured at a weak point. Or some other hypothesis. But what was clear was that a piece of silastic remained in the patient.
Many surgeons will say that the rest of the drain needs to come out.
But, going back in means opening the wound, and exposing the implant to potential infection.
There’s risk of infection with going back in. There’s risk of infection with leaving the wound alone.
Part of the calculus becomes a matter of optics. Patients expect that we will not leave needles, drains, or surgical tools inside of them. But, we don’t chase all bullets in trauma patients just to get a clean X-ray.
A real risk-benefit analysis must look at the added risk of fishing out the fragment.
No doctor wants to be that defendant explaining why a drain fragment was left in. But, if a patient experiences an added complication just because of the optics, have their interests been served.
There’s no perfect answer to this dilemma.
What do you think? Tell us below.
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Tell the patient asap.
Present the patient with all the options and document it.
Stop using drains and if you do, do not suture them.
Stop using implants and inject fat, it is 1000’s times better.
Do bloodless dissection, minimize trauma to area. use fingers.
The patient needs to be informed of the trapped or retained drain. The wound needs to be explored and the drain removed. The infection risk would be about the same. However if the wound does get infected, the drain would be implicated and the implants may need to be removed. In the case of bullets, they are hot when entering the patient and sears the skin on entry. It is a moving bullet that causes damage. An un-intentionally retained foreign body has a much higher liability risk than a re-exploration.
Jp’s do not prevent hematomas, they drain seromas.
Retained drains should be removed durin the periop period. Use of the drain is usually explained to the patient and failure of the device is part of the surgery. Just as implants can fail, jp’s can, too.
Just tell the patient it’s rare, take it out and don’t charge the patient.
I agree with all of the information presented. There is another aspect to consider and that is the untoward potential effects that could occur. An example:
A patient who was intubated properly in the operating room, documented with appropriate breath sounds, and ventilation (in the days before end tidal CO2 monitoring), was undergoing a routine procedure that was going on for an extended period of time. (Clearly if the tube had been out of place hypoxic cardiac arrest would have occurred early on). The patient due to other factors expired on the table. The endotracheal tube was left in place, and the patient after the code blue was complete and the patient pronounced, was appropriately transported to the morgue. In those days, the morgue was in the basement of the hospital but not necessarily in the same building as the modern ORs. The stretcher with patient and nurse, and resident went up hill and down hill in the basements of the buildings to get the patient to the morgue. An autopsy was performed. The endotracheal tube was found to be in the esophagus and the anesthesiologist was sued for malpractice, the presumed cause of death was esophageal intubation and hypoxia. Given the circumstances (the tube was secured in place, the patient was not moved for the procedure, and CPR did not dislodge the tube) the only reason for the tube being found in esophagus was the transport post arrest.
I was not involved in that case but did get to hear about it after the fact. I did not understand until I heard about another transport of a patient post arrest, (without endotracheal tube) to the morgue. Typically the most junior personnel are assigned to this task while more senior personnel are left doing documentation in the record. Let’s just say that transporting a patient on a stretcher up and down ramps between different buildings is not easy and it become understandable how things can be dislodged from their existing position.
Cycling back to the current case under discussion, I would carefully explain the situation to the patient including potential for drain migration. I would never leave suturing of the drain to the most junior personnel. I would test the drain to make sure that it slides appropriately, well before complete closure and before the skin locking stitch is put in place. I would depend more upon appropriately secured tape to the skin, and less to suture material. I would wholeheartedly recommend excision of the drain as soon as practical. If the drain is out, and the rapport is good, a mistake will be understood by the patient, and hopefully a lawsuit will not result. IF the patient goes to another surgeon for excision, a lawsuit is planned.
I have been there. If I use a drain (rarely, in total joint arthroplasties), I tell the family that my PA will come by and pull it out the next day, and that it will likely come out without a problem. I do mention that there is a remote chance it may not — in which case a return to the OR will become necessary.
Kinda depends on the patient, doesn’t it? You have to be upfront and tell the patient that part of a drain remains. If the patient is totally stoic and doesn’t seem to be concerned, then you have reasonable cause to do nothing until and unless something changes. That would probably be a rare patient. My guess is that the average patient will likely want it removed, and doing it sans charge is the obvious thing to do.
Seems like a no-brainer to me.
And while Dr. Shakespeare definitely took credit for the saying, most of the big guns credit it to Dr. Marlowe; a few say it was Dr. Congreve. I personally think it was Congreve’s PA.
First don’t panic. The patient should be informed of the occurrence and all of her options. The consequence of leaving the drain portion in place may be minimal vs the morbidity associated with opening the wound to retrieve the drain.
It certainly is no emergency to remove the drain. If the patient and surgeon decide mutually to leave the drain remnant in place it should be documented in the chart (of course) with all risks, benefits and alternatives outlined.
If the decision is made to simply observe the patient then close observation for any adverse effects such as pain, palpability, visibility or signs of infection should prompt consideration for exploration and removal.
If no problems arise, then the drain can also be removed in the future if there are other indications to return to surgery such as in a staged procedure (breast reconstruction) or for implant replacement should that be necessary in the future.
I agree with Dr Levens.
Years ago we had this problem with an abdominoplasty drain. We explained the situation to the patient, offered removal, and she elected to leave the fragment in place. To my knowledge, she never had any difficulty with it.
To me, full disclosure and acceptance of the patient’s choice is the answer.
JPs are radio-opaque, and measure possibly 6-8 cm in length. If the stab incision for placement is not wide enough, it’s conceivable that the entire drain fractured at the neck, and removal should be uneventful, and probably a good idea.
If a suture caught the distal drain, far from the scar, and a sub-centimeter piece of JP silastic is asymptomatic, the choice will be up to the patient after the pros and cons are weighed. A 5mm fragment of JP silastic under a half pound silicone implant is a much different scenario than a 5 cm radio-opaque snake.
Thank you.
Boarded in both Ob/Gyn and cosmetic surgery, I am very comfortable with performing ultrasound to determine size and location of postop seromas and drain them under ultrasound guidance.In the case mentioned above, the remnant of the drain should be easily located and removed through a small incision under ultrasound guidance under local anesthesia. Many cosmetic surgeons have ultrasound technology in their office or have access to one and should use them if necessary.
i can’t imagine leaving any foreign body adjacent to the implant. I wouldn’t give the patient a choice; i’d take her back right away at no charge. She could of course refuse, but i’d press her hard to do it.
That would be my position with any procedure i can think of, but would be particularly important here given the risk of capsular contracture, and the near certitude that there would be at least some staph epi in or around the drain. As we now know, staph epi biofilm is probably the culprit in most capsular contractures.
Aside from that, the data is clear that drainage of a primary augmentation is unnecessary. It would not be “gross negligence,” but i can’t think of a community in the US wherein which uncomplicated primary augmentations are drained.
Confirm that there was a retained fragment and its location. Location may actually be a decider for some doctors/patients, especially if close to the wound and palpable.
Immediately inform the patient. I would remove the fragment right away. In my experience, this is due to a suture either looping the drain or the needle going through the drain. In any event, get it out and forget about it. Leave it in, and you are on the hook forever and hence, can’t ever be comfortable.
The patient needs to be informed and the drain needs to be removed. Otherwise its a retained foreign body after surgery. How do you defend that?