DRAINAGE (fr. drainer - to drain) — the medical method consisting in removal outside of separated from wounds, abscesses, contents of hollow bodies, natural or pathological perigastriums.
Drainage in surgery
At the time of Hippocrates, Ibn-Sina and A. Paré applied metal drainages from silver, copper and tin to treatment of wounds. Carry out by means of rubber, glass or plastic tubes, strips of rubber or specially made plastic strips (fig. 1), gauze tampons entered into a wound or the drained cavity. For drainage various soft probes and catheters can be used. The greatest distribution was gained by rubber or plastic tubes of various diameter. When it is necessary to enter into the drained cavities antiseptic or medicines or in the presence of indications to washing of cavities, are used two - and three-channel tubes (fig. 2 — 4). For improvement of outflow of contents on one end of a tube make one or several openings which number and the sizes are defined by diameter of a tube and the sizes of the drained cavity.
The drainage tubes of Redon which gained distribution among foreign surgeons have length of 50 — 52 cm at internal to dia. 3, 4, 5 and 6 mm (with number of openings to 56).
On physicomechanical and toksikol. to characteristics, quality of surfaces the drainage tubes made of natural latexes, silicone rubbers and polyvinyl chloride plastics fullestly meet the qualifying standards. Polyvinyl chloride tubes have the greatest transparency and are much cheaper than latex and silicon drainage tubes.
At drainage of surgical wounds preference is given to tubes from silicone rubbers which according to the resilient-elastic characteristics, hardness and transparency are intermediate between latex and polyvinyl chloride tubes, but considerably surpass the last in a biol.inertnost that allows to increase terms of stay of drainages in wounds. They can be repeatedly subjected to sterilizing processing by autoclaving and we heat (to t ° 200 °) air.
As a rule, drainage tubes shall be made of X-ray contrast polymeric materials that gives the chance to exercise control of introduction of a tube to the drained cavity and of its arrangement in this cavity in the course of treatment. For overseeing and for simplification of the subsequent shift and sterilization of the sites of drainage system which are out of a wound in it arrange with character of the emitted liquid so-called control windows from short glass or plastic tubes — adapters (fig. 5). The possibility of penetration of an infection into depth of a wound on a gleam of a drainage is prevented replacement double within a day on sterile all peripheral part of drainage system, including the graduated vessels for the collecting separated. On a bottom of the last usually pour antiseptic solution (Furacilin 1: 5000, Diocidum 1: 1000, Rivanolum 1: 1000).
A number of requirements is imposed to D.:
1. Shall provide to outflow of liquid throughout all term of treatment of a cavity, a wound etc. Loss of drainages can be the serious complication burdening the result of surgery. The prevention of it is reached by careful fixation of a drainage to outside integuments bandage, an adhesive plaster or a silk seam, it is the best of all for the rubber coupling which is put on a drainage tube near skin.
2. The drainage system shall not be squeezed or bent both in the depth of a wound, and out of it. The arrangement of drainages shall be optimum, i.e. outflow of liquid shall not be caused by need of giving to the patient of forced situation in a bed.
3. Shall not be the cause of any complications (pains, decubituses of fabrics and large vessels, etc.). Rather fully natural evacuation of liquid from the drained cavities on system of hollow tubes by the principle of a siphon conforms to these requirements. In some cases apply forced aspirating separated under small negative pressure by means of water-jet suctions, etc. (see. Aspiration drainage ). The easy way of aspiration separated by means of the rubber barrel attached to a drainage was offered by M. A. Kimbarovsky.
At D. of deep purulent wounds and purulent cavities drainages enter into a cavity of a wound through the main or additional cuts, counteropenings (see) which make for ensuring the best outflow separated. For effective D.'s providing with the patient give the situation promoting outflow of wound contents, free in gravity. The siphon drainage is applied, e.g., at D. of bilious ways. At D. pleural cavities apply a siphon drainage across Byulau (see. Byulau drainage ). After a pneumonectomy and at treatment of empyemas of a pleura apply the sucking-away drainage according to Subbotin — Pertesu or the water-jet or electric vacuum device (see. Aspiration drainage ). The siphon drainage system used by foreign surgeons supplied with the back pressure valve is reasonable. The back pressure valve of petal type is placed in the transparent plastic cylinder with densely put adapters on the ends (fig. 6 and 7). All valve device consists of two semifixed elastic cylindrical cameras from which the lobby serves for initiation of the expiration of liquid from a pleural cavity by periodic squeezing as fingers of its walls, and the second represents actually valve device, a cut it is convenient to use for drainage by means of the sucking-away devices.
For implementation of drainage of chest and belly cavities in a number of the countries release trocar catheters from polyvinyl chloride plastic compounds or silicone rubbers complete with a trocar stylet for one-time (in sterile packaging) or repeated use. These catheters enter along with a trocar into the drained cavity and connect to the closed drainage system after extraction of a trocar. The drained cavity, thus, is always closed and is not subject to influence of outside pressure. In case of an unsuccessful puncture it can be repeated in other point without any complications since a smooth distal cone the trocar stylet, made of stainless steel or light alloys, is fitted by a catheter tightly and cannot cause additional damages. On the distal end of a catheter there are two additional side openings; the gleam of each of them is equal on the area to a gleam of the internal channel.
Trocar catheters release even counts from the 10th on the 32nd inclusive with a length of 20 — 40 cm and more; number 10 — the 18th uses hl. obr. as nurseries. For determination of depth of introduction 2 — 3 divisions through each 5 cm
of D. widely are applied on catheters apply in surgery of bilious ways, especially D. of a gall bladder and outside D. of the general bilious channel, a cut for the first time executed through a stump of a vesical channel in 1891 Mr. R. Abbe and through a section of a wall of the general bilious channel in 1892. Lane (W. And. Lane). To W. Korte applied the drainage with a side opening providing along with outside removal of bile receipt of a part it in a duodenum. H. Kehr offered for D. of bilious ways Y-shaped, Diver (J. Century of Deaver, 1904) — T-shaped drainages. A. V. Vishnevsky in 1925 offered original «a drainage — a siphon manometer», at Krom the drainage tube with a side opening is entered into the general hepatic canal. E. V. Smirnov (1950), D. L. Pikovsky (1964) recommended after a cholecystectomia for a decompression of bilious ways of D. of the general bilious channel thin plastic tubes through a stump of a vesical channel. At recovery operations on the extrahepatic bilious ways Follker (F. Vollcker, 1911) applied plastics on a rubber drainage which removed outside through a duodenum. Praderi (R. Praderi, 1961) offered outside transhepatic D. of hepatic bilious channels (see. Choledochoduodenostomy , Choledochostomy , Holetsistogaspgrostomiya , Cholecystoduodenostomy , Cholecystostomy , Holetsistoenterostomiya ). Introduction of rubber or plastic drainages is often combined with leading of gauze tampons or apply the so-called cigar drainages offered by S. I. Spasokukotsky, consisting of the gauze tampon placed in a finger of a rubber glove with the cut-off end. For the best outflow of contents in rubber covering do several openings. «Cigar» drainages, unlike gauze tampons, are taken easily, without traumatization of fabrics. Use for D. of gauze tampons is based on hygroscopic properties of the gauze creating outflow of contents of a wound in a bandage. For treatment of big deep wounds and purulent cavities I. Mikulich in 1881 offered a way D. gauze tampons, at Krom the square piece of a gauze stitched in the center by long silk thread is entered into a wound or a purulent cavity. The gauze is carefully straightened and cover with it a bottom and walls of a wound then the wound rykhlo is tamponed gauze tampons. Tampons change periodically, without changing a gauze that prevents damage of fabrics. If necessary the gauze is taken pulling up for silk thread (see also Tamponade ).
Apply also to introduction to cavities of antibiotics, and also to timely removal of liquid and contents after operation on hollow bodies for the purpose of prevention of formation of zatek and development of peritonitis in case of insufficiency of seams. E.g., after a cholecystectomia the rubber drainage and tampons bring in subhepatic space that in case of sliding of a ligature from a stump of a vesical channel bile through a drainage was taken away from an abdominal cavity. After abdominal organs operation and at treatment of peritonitis widely apply D. to prevention of paresis of intestines of a stomach and intestines the stylet entered in Nov, and sometimes and D. of intestines by means of an enterostoma (see. Enterostomy ).
Of an abdominal cavity — the main method of treatment at the delimited abscesses of an abdominal cavity of any localization. At diffuse purulent peritonitises apply D. to peritoneal dialysis (see) or enter drainages into additional counteropenings for improvement of the outflow separated from an abdominal cavity.
For treatment of ascites, an edema of a brain, at reconstructive operations on the extrahepatic bilious ways apply internal. Unlike outside, at internal D. drainages remain in fabrics for continuous outflow of liquid in hypodermic cellulose or cavities or for formation of channels at recovery operations. For internal D. at an edema of a brain use an autoplasty of a vein (R. E. Payr, 1911), a tube from a meninx (R. I. Venglovsky, 1913), an epiploon, polyethylene and rubber drainages. Thanks to D. excess cerebrospinal liquid is taken away from a head cavity or the spinal channel in an abdominal, pleural cavity, in retroperitoneal space or in an ear of the left auricle. At ascites apply an epiploon to constant internal D. (see. Talmas — Drummond operation ), bunch of silk threads; at recovery operations on the bilious ways — rubber and plastic drainages.
In certain cases resort to use of the so-called hidden or forgotten drainages which are especially widely applied in surgery of bilious ways. The hidden drainage entered into the general bilious canal and in a duodenum, if necessary can be taken by means of a duodenoskop. Rubber and plastic drainages put pressure upon fabrics and at long D. can cause heavy complications — an arrosion of blood vessels, decubituses of a gut and other bodies. Therefore at D. it is necessary to avoid contact of drainages with large blood vessels and to timely take drainages. D.'s terms are various. So, drainages from an abdominal cavity are removed in 7 — 8 days, from the general bilious channel — in 3 weeks. At D. of purulent cavities drainages are taken after the termination of release of pus and reduction or almost total disappearance of a cavity.
Drainage in urology
At surgical diseases of bodies of an urinary system, and also at their fire and closed D.'s damages is an obligatory element of the vast majority of operational grants. The timely and technically correctly carried out D. is means not only preventions or elimination of a number of heavy complications, but in some cases and the independent purpose of operative measures.
D.'s need is caused as the anatomic features of bodies of an urinary system creating premises for accumulation of the streaming contents of uric ways and wound separated in the friable mass of cellulose of lumbar areas, retroperitoneal and pelvic space, and the aspiration to prevent harmful effect of urine on surrounding fabrics.
The disturbance of an integrity of walls of urinary tract resulting from a fire injury, the closed damage or during operation, inevitably is followed by the subsequent constant allocation of contents of an uric path in adjacent fabrics since bodies of the uric highway, except for a top of a bladder, are deprived of serous covers, and even careful sewing up of an operational wound of uric ways does not provide the full moisture isolating Hermeticism and does not allow to avoid infiltration of urine through the line of seams within several days, until healing of the damaged urothelium. During this period of D. warns possibilities of an ischuria and the fabric operational grant separated in fabric cracks and pockets in a zone.
The purposes, methods, technology of performance and means of implementation of D. are very various and caused by specific conditions. However the general principle D. in urology is creation of conditions for free and full assignment of contents of uric ways and fabric separated, excluding a possibility of their delay in any sites in the depth of a wound.
Distinguish two main methods D.: intralyuminarny and ekstralyuminarny. In the first case the drainage is placed in a gleam of urinary tract. It is accepted to call such drainage «functional» as on it the main removal of urine is carried out. Depending on D.'s problems removal of urine by means of this method can be short-term, long or constant. D. of a renal bed at plastic surgery on a lokhanochno-ureteric segment at a hydronephrosis can be one of examples of short-term removal of urine. D.'s problem in a similar case — creation of a dormant period and optimal conditions for healing of seams in a zone of an anastomosis. In need of recovery of sharply broken azotovydelitelny function of kidneys and the compensations expressed secondary morfol, changes of uric ways as a result of the obstacles preventing outflow of urine at the different levels of an uric path resort to removal of urine for long terms. Similar D.'s carrying out as the first stage of an operational grant carries the name «unloading» or «decompressive» and is carried out at treatment of patients with nek-ry forms of an extrarenal anury, patients with adenoma of a prostate, at inborn obstructive diseases of bodies of the uric highway at children, etc. From kidneys resort to constant, lifelong removal of urine at patients with occlusion of pelvic department of ureters with cancer infiltrate, coming from a bladder, a prostate gland, female generative organs, etc.
At ekstralyuminarny D. the drainage is located out of a gleam of uric ways — at the line of seams, the place of defect of a wall of body, in sloping sites of a wound and its pockets. Such drainage call «safety» as its appointment — catching and removal of the urine filtering and accumulating in the depth of a wound and wound separated. D.'s terms are dictated by the nature of a disease and the complications caused by it, features of an operational grant, and also the positive changes of a condition of uric ways reached as a result of D.
The first take safety drainages. Necessary premises of removal of a safety drainage — on it wet the termination of allocation or wound separated within 1 — 2 days. A condition of extraction of a functional drainage at intralyuminarny D. — recovery of a normal passage of urine and full passability of uric ways distalny places of standing of a tube. For the purpose of check of passability carry out so-called colourful test: after a perezhimaniye of a tube from the place of its fixing to skin via the syringe proksimalny a clip in it enter 5 — 10 ml of 1% of solution into 4 — 5 cm methylene blue or the same number of 0,4% of solution of indigo carmine. Intensive coloring of the urine emitted in the natural way in
15 min. after an injection of dye testifies to positive takes of a research. After that the drainage is a little tightened, removing from a gleam of uric ways and transferring to the provision of safety. The termination of release of urine on a drainage in 2 — 3 days allows to take it completely. Removal of a drainage without check of passability of urinary tract can lead to formation of constant uric fistula in the location of a tube, to development of an ureterohydronephrosis or development of apostematous pyelonephritis.
In all cases of D. use of drainages from polymeric materials is more preferable (especially silicone). Unlike rubber, they even at long stay in fabrics cause the minimum reactions and in their gleam there is no adjournment of uric salts. Depending on character and problems of an operative measure, an anatomic condition of uric ways for D. apply tubes of various diameter and a gleam, as well as special two-channel drainages to carrying out simultaneous washing or medicinal irrigation of uric ways. Apply also special two - and three-channel catheters of Foley (fig. 8.).
In the figure 9 the three-channel catheter of Foley after his introduction through an urethra to a bladder is shown.
The catheter has on the distal end a barrel and two or three drainage openings in a wall. The gleam of each of openings is equal on the area to a gleam of the main channel if for any of several reasons one of openings will be impassable. For the purpose of increase in a gleam Foley's catheters can have the thinned walls reinforced by a kapron spiral. Walls of a barrel in its unfilled state densely adjoin to a surface of the distal end of a catheter, without complicating introduction of a catheter through an urethra. Filling of a barrel is made by means of the syringe «Record» via the auxiliary channel, on the end day off of a tube to-rogo is available a bell with the back pressure valve. The volume of filling of latex barrels makes from 3 — 5 ml (nurseries) to 50 ml and more. The barrel after filling its sterile a dist, Vod or fiziol, solution interferes with loss of a catheter.
Latex barrels do not stick to walls of a bladder even when they are used for packing of a wound surface after an adenomectomy.
Administration of wash liquids or medicines is made via the second auxiliary channel, on the end day off of a tube to-rogo is available the bell supplied with either a locking cover, or a tapered plug or a special bell-shaped faucet.
The central drainage channel of a catheter is always open for outflow of liquid and is connected or to the suspended soft collection from a polymer film, or with a glass or rigid plastic capacity which have graduation for determination of amount of the removed liquid.
Drainage at kidney operations can be the independent purpose of surgical intervention or be carried out as the final stage of various types of operational grants. However in all cases of D. of a kidney puts a task to create optimal conditions for its function and it can be carried out in two ways: 1). Of lokhanochno-cup system through thickness of a renal parenchyma (fig. 10) — so-called. nephrostomy (see); 2) Through a wall of a pelvis — so-called. pyelostomies (see). At a nephrostomy use special catheters of Brandenberg and his modification. All catheters for post-operational D. of a kidney are graduated on length of 30 — 40 cm (since the distal end) through each centimeter.
Drainage at operations on an ureter. At a section of a wall of an ureter of D. it is usually limited to leading of a tube to the place of defect of a wall or the line of seams. At a resection of yukstavezikalny department of an ureter and its neoimplantation in a bladder, and also during the performance of anti-reflux operations on a vesicoureteral segment D. carry out by introduction to a gleam of an ureter of a spaghetti, to-ruyu remove near tsistostomichesky drenazhy. Similar interventions usually complete D. of retroperitoneal pelvic space through a locking opening across Buyalsky — Mac-Uortera (see. Bladder ).
Drainage at operations and traumatic injuries of a bladder and urethra
of a cavity of a bladder can be reached by D.: 1) introduction for a certain term of a rubber catheter through an urethra (a so-called constant catheter); 2) in the operational way through an extra peritoneal part of a front wall (a so-called high cystotomy — sectio alta). The first has limited use at indications, special to that. The high cystotomy is applied for the purpose of longer temporary or constant removal of urine from a bladder at existence of an obstacle to outflow of urine through an urethra and at injuries of a bladder or urethra. At extra peritoneal ruptures of the bladder of a traumatic or fire origin, especially if they are followed by a change of haunch bones and zateka of urine in lower parts of paravesical cellulose, D. of a bladder and cellulose of a basin is necessary in the earliest terms from the moment of an injury, In these cases carry out D. through a locking opening across Buyalsky — Mac-Uortera. At the diseases and injuries of a spinal cord which are followed by frustration of an urination apply long D. of a bladder on Monroe, essence to-rogo consists in creation of the permanent siphon system allowing to alternate filling of a bladder to its emptying. In addition to washing of a bladder for fight against an infection, Monroe method promotes recovery of a reflex on an urination.
When there is no need of washing of a bladder, it is convenient to D. to carry out it by means of a dvukhprosvetny catheter of Foley connected through an intermediate tube by length apprx. 1,5 m and to dia. 7 — 9 mm with the collection of urine. It is convenient to use the connecting tubes having a rubber cover which stretches on a mouth of the collection on one end and reliably holds in it the end of a tube (fig. 11).
The catheter can be connected with suspended to a bed (a rack, etc.) the soft graduated collection with a capacity from 100 to 2000 ml (fig. 12) having an additional drain tube with a clip. Advantage of such drainage system consists in a possibility of constant maintenance of its sterility.
Drainage catheters can be made of the latex containing silicone additives. At the expense of these additives degree of swelling of walls of a catheter decreases, they do not stick to fabrics, salt sedimentation practically does not happen within several weeks.
Of a bladder apply to D. also bulbous catheters numbers 12 — 40 on Sharryer's scale. Length of a catheter is 30 — 40 cm.
After some ginekol, operations, at strictures of an urethra, adenoma of a prostate and in some other cases of a bladder it is convenient to apply the closed drainage systems to suprapubic D. During the use of such system on skin of a stomach of the patient paste a porolated film from silicone rubber with the fixer attached to it for a catheter. Through the central opening of a film make a puncture of an abdominal wall in suprapubic area a special trocar with a plastic cannula, through to-ruyu later extraction of a trocar from it enter a catheter (fig. 13) made of soft silikonizirovanny elastomer into a bladder. The proximal end of a catheter 20 — 25 cm long is attached through a three-running plastic faucet to siphon drainage system. The main advantage of such system in comparison with system D. through an urethra is that it provides more prematurity of spontaneous bladder emptying and reduces danger of infection it. Existence in system of a three-running faucet gives the chance, without separating it, to carry out washing of a bladder.
Bibliography: M. A. Drenazhnoprovodnikovaya's frost needle and technique of drainage, Klin, hir., No. 9, page 82, 1964; The Guide to clinical urology, under the editorship of A. Ya. Pytel, M., 1970; The Guide to pulmonary surgery, under the editorship of I. S. Kolesnikov, L., 1969; The Guide to an urgent surgery of abdominal organs, under the editorship of V. S. Savelyev, M., 1976; Skripnichenko D. F. Urgent surgery of an abdominal cavity, Kiev, 1974, bibliogr.; Smirnov E. V. A drainage of a holedokh through a vesical channel after removal of a gall bladder, Vestn, hir., t. 104, No. 4, page 35, 1970, bibliogr.; Chirurgische Operations-lehre, hrsg. v. A. W. Fischer u. a., Lpz., 1957; M a y o r G. u. Z i n g g-E. J. Uro-logische Operationen, Stuttgart, 1973.
D.F. Skripnichenko; Century of H. Yermolin (Ur.), P. P. Sherstnev (tekhn.).