intraabdominal drain

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IS INTRAABDOMINAL DRAIN A MUST AFTER LAPROSCOPIC CHOLECYSTECTOMY ? A 3 YEAR REVIEW Dr Rohit Shyam MS, Dr R.R. Kumar MS, Dr A K Singh MS .Durgapur Steel Plant Hospital, Steel Authority of India Ltd. Durgapur

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Overview when in doubt, drain ' - Lawson Tait, ' no drainage at all is better than the ignorant employment of it '- Halsted The hardest thing in surgery is to stop something that has been done for years

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Overview Hospital stay is longer when a drain is placed Drains increase the rate of wound infections Higher incidence of nausea in post operative period when there is a drain. Drains help in expulsion of CO2 after laparoscopic procedure. Controversy regarding the type of drain and duration of its application.

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AIM The study is aimed at determining the evidence-based value of prophylactic drainage in routine laparoscopic surgery (GI) surgery at our hospital and develop a scoring system that allows to decide objectively “to drain or not to drain”.

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The METHOD A retrospective study on 532 patients operated in last 3 years in the department of surgery at DSP Main hospital was carried out . Outcome based analysis was done regarding the usage of intraabdominal drain.

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The METHOD A Scoring system was designed including Difficulty of operation , Operating time, Hemostasis , Experience of surgeon , Infrastructure available to manage complications . Each of the variable was given a score 1 or 2 . The final score was compared with the incidence of drain usage and post operative comorbidity.

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The METHOD Group A: Surgery was performed using conventional four ports umbilical port, port below xiphoid and two ports below right costal margin. Pneumoperitonum at pressure 12 mmHg. Drain was put after the procedure in the GB fossa . Group B Surgery was performed using conventional four ports umbilical port, port below xiphoid and two ports below right costal margin. Pneumoperitonum at pressure 12 mmHg. no drain at the end of operation.

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The METHOD Both the groups under the procedure under general anesthesia and received one dose of third generation cephalosporin pre-operatively. The Intraoperative parameter observed included duration of the operation. The post operative outcome was assessed in both the groups in terms of hospital stay , use of analgesics , anti emetics , overall comfort of the patient. No patient was discharged with drain except in referrals . Pain was scored on the patient complains and need for injectable analgesics (NSAID) Injectable ondasetron was used for complains of nausea Sutures were removed on the post operative 7 th day.

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OBSERVATION PARAMETER number AGE 48 mean , range 24-78 years. FEMALE 314 MALE 218 COMORBITY HYPERTENSION DIABETES 192 117 PREVIOUS OPERATIONS 75 HISTORY OF JAUNDICE 55

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OBSERVATION GROUP A: 468 (A size 16 fr NG tube was used as drain in all cases ) GROUP B: 64

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OBSERVATION CRIETERIA SCORE 1 SCORE 2 DIFFICULTY OF OPERATION EASY 178 DIFFICULT 354 OPERATING TIME <2 HRS 394 >2 HRS 138 HEMOSTASIS DRY 256 OOZY 276 EXPERIENCE OF SURGEON TRAINED “BOARD CERTIFIED “ 532 SELF STYLED 0 INFRASTRUCTURE TERTIARY CENTER, OC, ERCP, HDU 0 NURSING HOME, SINGLE UNIT 532

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OBSERVATION Attribute Group A(468) Group B(64) Ratio(A/B) age(mean) 1 42 1.21 Male 198 20 9.9 Female 278 36 7.72 Hospital stay (days) 2.4(2-6) 1.6(1-3) 1.5 Top up analgesia 24 3 8 Vomiting 56 1 56 fever 19 1 19 Biliary fistula detected 2 0 Infinite! Wound infection 4 1 4 INFINITE

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Recommendation Although the literature is replete with data indicating that drain is not indicative in routine lap-chole cases, we found that in the settings with limited resources , putting a drain is very cost effective than managing complication subsequently. The drain score system showed retrospectively that the drain was used more often in the cases with a score of 6 or more .

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Recommendation Still we recommend that the final call should be that of the operating surgeon for putting the drain . With increasing experience the incidence of putting the drain will definitely reduce . This perhaps should be the healthy learning curve pattern

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THANK YOU References: Kazuhisa Uchiyama, Masaji Tani, Manabu Kawai, Hiroshi Terasawa, Takashi Hama, and Hiroki Yamaue. Clinical signifi cance of drainage tube insertion in laparoscopic cholecystectomy: a prospective randomized controlled trial. J Hepatobiliary Pancreat Surg (2007) 14:551–556,DOI 10.1007/s00534-007-1221-x Sanjay K. Bhasin , J.G. Langer . Laparoscopic Cholecystectomy :An Experience of 200 Cases. JK SCIENCE Vol. 6 No. 2, April-June 2004 Victor Zaydfudim & Robert T. Russell & Irene D. Feurer & J. Kelly Wright & C. Wright Pinson. Drain use after open cholecystectomy: is there a justification? Langenbecks Arch Surg (2009) 394:1011–1017 DOI 10.1007/s00423-009-0549-x DR. Abdul Ghafoor, MS,DR. Irfan Shukr, FCPS,DR. Abdul Nasir, FCPS. CHOLECYSTECTOMY;IS DRAINAGE NECESSARY? Professional Med J Dec 2008; 15(4): 437-439. / PROF-1333

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