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OK. OK. So, so definitions, they are devices uh connecting. So they are appliances or devices that act as deliberate channel for each establishing potential collection of blood or infi fluid to re and the drain to allow surgical uh healing and the gradual collapse and the opposition of tissues. Quick overview of history. This is actually um in Owa, a city in Egypt. Um where, where, where you can find a surgical tools printed like this. And the first surgical green described when they used a superficial wound, uh er closed over a piece of cotton to drain this infection. And then 3 75 before Christ uh Hippocrates, uh uh first treated for USIS with combination of endotrachial intubation and um the surgically drain that lived in this age. Uh then Romines take this. And then in 18 87 lo lo lo said when you are in, when you are in doubt, leave a drain. But whether if this correct or not, you should think about the uh benefits or what's called the advantages and of advantages of leaving a dream. First, you can decrease the risk or the rate of anastomotic le by evacuating seroma and the blood that once infected can lead to abscess formation. So to decrease the risk of complications, number two, to, to decrease the severity of these complications by early detection and diagnosis and then facilitate the diagnosis of intraabdominal peritoneal hemorrhage. For example, when you have this Brad Jackson drain up there or this ect drain, you can think about if the amount of blood increasing and it is purely red sanguinous, then you think an HB is a dropping, then you think about are we bleeding there or? Uh so these are the benefits. But this advantage is actually when you leave a drain, you stimulate further formation of serious flow and this can lead to infection from outside as well. And you can also increase the risk of leakage by preventing mobilization of omentum uh and obstructing the normal healing mechanisms and it can be rule off quickly and blind you or hinder your vision about what you are thinking. Uh the bene about the benefits. If you leave a trainer, the types of drains, actually, you, you see a lot of drains. If you divide them by these uh parameters, mechanism of action or mechanism, is it under active suction or passive via atmospheric pressure? You just leave it without any uh suction nature. Is it a tube or sheat or flat? And I is it open suction or open or closed and location? Is it internal or external? Sometimes you think about, for example, if you have pseudo a cyst of the pancreas and you are trying to convince your in house radiologist to do drainage for you. Then it says like it's adherent to the bowel. Speak to me about internal drainage like from this collection to the stomach, which is called internal drainage cyst to gastrostomy. Is it inert or irritant material? So passive like this one? What is this one? Because this session actually extension from the last session you should be aware. You should really know this. What is this one? The new one, corrugated rubber drain. Excellent. And what is this one? This is pin rose drain and this one is actually the saone nasogastric drain. This is called passive no suction. You just leave them open like that active. This one is called drain. This one is electric vacuum drain and this one is Brat Jackson Dr and we will show you some types of when to use it in the past. They use it for superficial uh infected in instead of, you know, when you have this aqua cell, you leave this spin rules with this safety pin on it. Corrugated rubber drain. They used it in India uh in the in the first instance to drain. Uh If you are in doubt about seroma collection, subcutaneous in the abdomen, ok. This is red rubber, corrugated drain first used in India and corrugated drain in the subcutaneous tissue before on the closure. As you see here, Brad Jackson drain. If you see this will be under suction and active suction, you leave it for uh for example, uh post uh post surgical and rectal cancer or you are worried about collection. But we will come to this point when you leave drain and the drains are not just simple. There are complex drains and this one is for uh postoperative pancreatic fistula. This is uh some people use this complex drainage system and whipple procedure which is pancreaticoduodenectomy for uh cancer and pancreas. So, the purpose of the dream, as you can think, it could be therapeutic, it could be palliative and it could be diagnostic and uh it could be prophylactic therapeutic when you think about a drain that permits the exit of gasses and liquids could be used to treat conditions like hydrocephalus, urinary retention. Even urinary catheter is considered a drain, abscess cavity disease or of tic drains, palliative, for example, by vas lunar obstruction. You know, when you simply put a a stent colonic stent is considered a brain diagnostic, for example, t tube cholangiogram as a post cholecystectomy diagnosis of retaining the stone and the common bile duct prophylactic to prevent uh postoperative complications that could arise from collections. Um ok, we will go through some examples of therapeutic and stuff like this. But before this, we need to think about when you leave a drain, especially in colorectal and upper eye surgery, for example, radiological drainage that's essential when you leave a drain like that for uh for a so abscess, this is so as abscess here, if you can see and this is if you see this arrow here. No. OK. This out of here. Mhm OK. This arrow actually is when you do radiological drainage ct guided, you will advance your tube as you see here. And once you advance this tube, you are going to think about um uh regression or aggression of this B time in four weeks time, the abscess is simply treated. OK. T cholangiogram or when you close. Um After, for example, if you have cholecystis and CBD stones, you have two options. Option number one is to get your MRC P or if ultrasound inconclusive, get your MRC P. And if MRCB shows CBD stones, you need to clear the bile duct before surgery, how to clear the bile duct is to uh option number one is to get ERCP. And option number two is to get uh intraoperative cholangiogram so that you can show on a monitor, what is the anatomy and what is the location of these stones and then you remove it by CBD separation at the same session. And if you can see here, um OK, this is actually the, this is the CBD expiation and this is when you leave a T tue in as a drainage in the and that's why it's called TU surgical drains. Actually, surgical drains. We have some in uh indications here and we need to ask when you leave a, when you leave a chest drain or when you insert the chest drain, what are the indications? Hemothorax, pneumothorax. What else? Ok. Excellent empyema. So they are thinking about air blood and what else? Post surgical and I will le esophagectomy. You can leave it, post cardiac surgery, you can leave it. And what else? What other source of fluid collection? Chylothorax? Ok. Which is the lymph? Ok. So these are simply the indications of a chest drain. We can read this scenario and think whether you need a chest drain for this scenario or not because we have a lot of cases when they ask you to insert the drain and send yours are happy. So anyone can read rea you can read the number 110 kg, 30 year old. Now lunch his injuries identified and completion on the bar. Ok. So you have, this is a chest x-ray and this is the open tibial fracture, tibia and fibula. So for example, would you leave, would you insert chest drain in this case or no? And why medicine would you leave a drain or no? Would you insert the drain or no? No. What else, Risa? No. Would you leave a surgical drain? Can you, you see? Ok. Tell us if you remember Moh's session about how to read the chest x-ray. Do you see any abnormality on this chest x-ray or no? Anyone see any abnormality? We need interaction come on. Yes. On the chest x-ray, you see small hemothorax apparent on the left side. So simply a chest drin is indicated if a hemothorax is sufficiently large to be seen on your chest x-ray. So you leave a chest dream. So the answer, this is RC Royal College of Emergency website, the official one. So you can number one bring the hemothorax and monitor and avoid tension of existing pneumothorax. Um So the answer is yes. Does he need a chest dr inserted while he's in? Ed? That's controversial. But this case is not necessarily if he remains stable, the procedure will be easier to be in c both test. And that's what we are thinking when you have a patient with chest or hemothorax, if it is stable, don't thrush probably for the upper fracture. So you can do that. Yes, in the same se excellent. So now you number two, where is Matthew? Please? Not at the a 36 year old alcoholic man has presented to you. He has been the victim of an assault as he can to go head. And so his ob over night have been general unremarkable. His chest x-ray again. It's the same question. Would you need a chest, a dream for this one or no? And no and anyone else I know you like this name. So OK. No. Uh I'm trying to see, I think, I think the OK. So I'm gonna say no, no, no, no medicine OK. So the answer is no stable patient with isolated chest injury and a chest pain showing a simple pneumothorax. Conservative approach is enough. Ok. So observe bit is observation is acceptable in selected patients when a small traumatic i thorax is there ok. A quick video about the chest brain. I know this picture is not correct but we can have some notices. Notice number one is that this chest drain here is below the patient level. That's correct. Number two, he's putting it under his armpit. And this, we know we don't know where is the opening. But the important point is that we need to make sure that if for pneumothorax, you need to make sure that there are some bubbling like that and also some olin oh and swinging of the level. Ok. So you need bubbling if for air for pneumothorax and you need ation of the level e either on the tube level or this level. And also you need to think about this prime mark. So the nurse will get this ready for you, but don't depend on that. You will find here something called the prime level. OK. Prime level. And you need sterile water at this level and it will cover only two centimeter of the tue. Ok? Ok. Let's get the video. Yes. By the way, the first step is the placement of a chest tube is to identify the insertion site. The insertion site is the fit intercostal space just anterior to the mid axillary line on the affected side. This can be found by using the nipple level as a landmark for the fit intercostal space. In females always be aware that the nipple may be displaced inferiorly due to large strenuous brith. In this case, remember to stay above the inferior mammary fold where the nipple would normally lie with the patient lying in behind position, the hand up and over the ipsilateral shoulder and secure it in this position to keep it out of the surgical field like that surgically and straight the chest and to predetermine the site of tu insertion using a small gauge needle locally anesthetized the skin and the subcutaneous tissue at the periosteum of the underlying rib impossible. The flare just past the rear should also be anesthetized. Make a 2 to 3 centimeter transverse incision parallel to the line of the ribs at the predetermined site of the up li the scalpel. While we dissect the subcutaneous tissue with the scissors or it dissects movement the top of the underlying rib until the next highest intercostal space is encountered with the tip of the hemostat puncture, the parietal portal. While pushing just at the top border of the rib. You must always enter the portal space over the top of the rib to avoid damaging the neurovascular bundle that lies along the groove and the inferior border of each rib. Be sure to enter the portal in a controlled fashion to avoid lacerating the, along with the hemostat. Once inside the port, spread the, the stent widely and withdraw it while still open to create a sufficient opening the chest tube. Before we're inserting the chest tube, place your finger into a hole in the floor. We move your finger around 360 degrees to confirm the replication in the full space by feeling the lung and making sure that there are no adhesions or impede to placing the chest tube. A large chest tube. A number 36 or number 40 French is used in trauma to allow for the evacuation of blood and clots collect the proximal and distal ends of the tube before an insertion, the distal plan will keep any blood from rushing out before it can be connected into a collection chamber. The proximal clap will assist in chest tube insertion but may not always be necessary or helpful. And then the chest tube into the pleural space to the desired length. All of the drainage holes should be well inside the chest cavity to provide a rubber seal and prevent leakage. The chest tube should be position posteriorly and aim superiorly in the tip cavity. This will allow for a maximum drainage and a super position. It may be possible to see walking of the chest with expiration and it may be possible to listen for it through air movement on the affected side, connect the end of the tube to an underwater seal apparatus collection chamber. OK. So four points here are important. Point. Number one is when you identify the site, you are just, you are in the fifth or the fourth is fine. Fourth intercostal space just anterior to the mid axillary line. Or we can say between the anterior axillary line and exterior alar line in l uh intercostal space, fourth or fifth and in males, you can take the nipple line as a landmark. Otherwise, in female, you can take the inframammary f as uh a landmark. And you need to think that when you insert the drain, you think about hourly monitoring of the vital signs is the amount is the color of the bleed or the air or whatever you need. Also to think about that. If it is blocked, you need to think about what are the indications of emergency thoracotomy. When you, you should speak to Saint George's and say we have now more than one liter and half of blood or whatever. Like there are, there are some indications listed for when you need to speak to a cardiothoracic surgeon for uh emergency thoracotomy, ok. When you leave the chest again, for example, you left, you already have postoperative chest x-ray and you are going to leave to remove the drain, how to remove the drain. Anyone if, if for example, um Mr Faried or Mr Mo put a drain in and he left and told you please remove the drain after like because today is less than 50 men and we are happy about this amount. It is stable and we remove the drain, how to remove the surgical chest drain. Uh So you get all your equipment ready. You gonna do the stitches around the gra inside, it's free. There should be a stitch left to seal all of after you explain how you get to do it, but you have to take some deep breaths in and out. And as they're expire, you probably just run out and they switch motion. Ok? Excellent. So you need to make sure that there is no ear ache, ear leak or anything will happen. So please try to plan the drain maximum, not more than six hours. So ask your nurse, I'm going to remove the chest drain in about four hours. Please clamp the drain and it's advisable that don't clamp the drain is because when you, when you clamp the drain, you need to make sure that you are not risking the patient for having a pneumothorax to prevent that this air leak will not cause pneumothorax. So clam the drain. And after no more than six hours, you go and ask the patient to take a a deep breath or do something called va man. So take a deep, take a deep breath and hold it. And then after, as you said, you will need to make sure that you have bursa string or a secure not. And with your fingers doing it like that close for, for air not to enter the pleural cavity causing the pneumothorax. You need to put your fingers on the edges like this and fora maneuver and you have your stitch ready because once you have a remove the tube, you will take your suture. Ok? And take a deep breath. Hold with me and then soft but go continuous traction and remove it. Don't worry, the patient will be in pain but you need to remove it. Ok? And then you take your stitch quickly and you can leave a ease of dressing. If you are worried about uh air uh uh that will enter from outside to in uh to inside. One was one other question when you should have a chest uh chest x-ray, ideally for removal. Yes. Straight away in two hours. Ideally as, as the Royal College of Emergency um or chem. Ok. So now I will I need to ask some of the resource why you leave a drain? Why will you leave a drain? For example, if you have appendectomy, I ask you for it in theater today. If you have appendectomy, why you leave a drain? When, because we have quite surgical procedures that we need to talk about when you are going to leave the drain. So some till now we think about this Morrison's pouch or HEPA pouch and the other pouch to fa cycle pouch that the fluid will be collected here and when you leave some drains here, you will expect that if there is collection, you will detect it, but that's not real. And this is never true. OK. We'll talk about appendectomy, Cholecystectomy and anastomotic leak prediction. OK. So before this, we need to finish that, you need to make sure that you have identified what is the type required? What is the purpose? Why you leave the dream and what is the location of the dream and its oral surgeon's preference according to the operative circumstances and patient conditions. Claritin Protocol can help stuff about. You need to monitor hourly. You need to uh when they should call you if the blood is above 100 or 200 whatever your instructions should be clear to the nurse staff in general. If active, the drain can be attached to a suction source ensures that the drain is secured and records the drainage output. Color amount and monitor is a fluctuation of the amount. Ok. Drains can be removed once the drainage has stopped or become less than some literature saying like 30 or 50 mil per day. But it is according to surgeon preference. And again, patient conditions and operative wise, drains can also be shortened by with the drawings then gradually and reassures the patients that the there may be some discomfort, analgesia should you should follow uh the pain control measures. Ok. Drain them as soon as possible. This is according to enhance the recovery of the surgery protocol and early removal is advised because we decrease the risk of some complications like surgical site infection evidence and controversy. Many gastrointestinal operations can be performed without any prophylactic drainage, even complicated appen sites. Pelvic drain may act as early detector of anastomotic leak. But that's again, not true. 100% in colorectal surgery. It's not routinely recommended in liver surgery as well in cholecystectomy is not recommended. But if you search the, the evidence, you will find that evidence. Level two, that esophageal surgery is advisable like I lo ectomy and all of that. Again, the same question for our registrars or our s will you leave a drain or no? For example, appendectomy when you should leave a dream for it when you should leave a dream because I'm not too sure about that in this online. And for example, when you leave a in cholecystectomy and in Appendectomy, not routine recommended in there is like oozing and control oozing. But uh you feel that much start to bleed again. We might leave a drain for, for 24 hours and take it out. It's not, I mean, the bleeding, especially, uh, if there is a bleeding, you have to control it, but it's not an indication for exactly. But it, the practice, some surgeons prefer to leave a drin like for peace of mind, but that's absolutely correct answer. But again, they are not advised if you are worried about, you said you you have already answered. You have already stated everything. So if you are worried about bleeding, you will control the bleeding. If you are worried about collection, you make sure that you have some washouts. If you are worried about biliary peritonitis again, while you leave a drink, it's a practice and we are stuck about this, but it's not routinely recommended at all. Ok. So, and we will come to some literature review about open appendectomy, uh open uh and laparoscopic cholet toy where the leaving adren will increase the hospital stay will increase the risk of postoperative uh collections and will increase the risk of surgical site infection and never, never decrease or detect. Uh it's not useful in detecting the collection because as again, I will show you funny picture when we come to this but you answered the perfect answer. Appendectomy tell if you go in and there's lots of puss, ok? In the pelvis. Ok. Um Most of the time we leave a drain ex or if you're concerned that there's bleeding around the stump. So like as a patient at the moment. Ok. So complete complicated appo you have gangrene, abscess, perforation, ok? In abscess and mass in appendicular mass, you don't touch. If you have appendicular mass, you don't do anything, you don't try to uh manipulate because otherwise you can show part of the small bowel and you are not sure. So leave a drain and go out in abscess. You can do washout, try to remove the appendix and leave a drain and go out. But in gangrene and perforations are not recommended at all. So, in this, in this publication, if you can see the study, um this is actually for open appendectomy uh or um the when they value with the prophylactic abdominal drainage, they, they have um actually collected from BM Science Direct Web of Science core library and in base database for they have included about how many patients. Uh So how? Yeah, I think so. Yes. Yeah, about 2000 articles, 2627 articles were reviewed and 15 high quality articles were eventually included. And if you look at this and read it, I will leave it. Uh again, prophylactic abdominal drainage did not benefit from appendectomy but increase the incidence of related complications, especially even if you have complicated appendectomy. That's for all appendicitis though, right? So that's for, I have searched all the literature. It's not routinely recommended at all for, for perforated appendix. Yeah, if you've got fecal matter in your abdomen, they wouldn't recommend draining it. No, no. If, if you have fecal, whatever if you have, if you have perforation is definitely no protein. And if our consultants are attended, attending, now we can ask them. But if you search appendectomy when you leave a drain. So we said maybe in abscess plus or minus in mass, definitely you will not touch this mass because that's why you will leave Adren and go out. But in gangrene appendicis when you have already secure, safe, healthy base uh on the s you don't need to leave a drain. Ok. But ok, but we need to expect or to monitor the collection or to prevent collection. Never a dream, prevent collection. I know we have this decision made many times in all, in many trusts and again, they will leave a dream. The practice is a practice but we need to think about if it is beneficial or not. No, again. Yeah. Yeah, definitely. When they say that a lot of those articles, those are the ones retrieved from the search, they may doesn't mean those that many articles have been published on the topic. It just what the search word retrieve the 15 are the ones that actually were on the topic. And you know, just always try to read between the lines between this analysis. I don't know about this one. I'm just in general and systematic reviews. It is junk in junk out. If you put bad studies, you get bad results and always question the the quality of the systematic review. Not just the, the systematic review. Again, I'm not judging this one. It just my comment about this would be is that we have no idea why the drains were put in in the 1796 patients. So, yes, it increases their length of stay and increases their postoperative complications but they probably don't know, app in the first place to a drin, there are 22 big studies for Appendectomy done some called drift study. And there is other one. If anyone reminds me, there is another study, it's a big studies. Big. Yes. Not for drains. For Appendectomy Rift. The study. And there is another study if you go for studying, if there is rift, the study and another study. So, they are comparing about everything when you like, for example, antibiotic versus, uh, appendectomy alone. Yeah. But they involved it, but they in involved it when you should leave a dream. And if you search, we can we up together if you search Appendectomy, if you have viant or whatever, there is no reasoning for leaving a dream, it's still, uh, sorry for leaving Adren and Appendectomy. So if you search, for example, Appendectomy, should I leave a dream on the literature? It's not routinely recommended. No, I completely agree with that. And I, I think leaving a drain routinely with appendicitis is complete the wrong thing to do. But my, my point is in this study, in particular is it just, is, was it like randomized? And they were just, it's not because it's, it's a, it's a, we have no idea why the drains went in, in those patients. So this is another point if you see something making a claim that, you know, it's surprising or it is, um, you know, you want to, to get into it. Don't just rely on the abs the option is just, you know, to pick your interest, then they into the study and see because they might say, oh, we did not include patients with fecal per, with um fecal peritonitis after due to appendicitis. So be very careful of what they include or exclude in terms of patients because this may not apply to you. Maybe they include all patients with appendicitis. But if you go to the subgroups, um you see there is a difference. So just you know, yeah. Yes. For, for as, as M sapa said, you need to identify PCOS or population intervention comparison and outcome and study design. But again and again and again, if you search any literature about this, especially so we have appendicitis, right? And we need to get out of this topic before getting out. We need to answer appendicular mass drain. Ok. Recommended of course. And appendicitis complicated gangrenous or with feli or per would you leave a drain? You have done your washout. Would you leave a dream? I wouldn't Fareed. Would you leave a dream? I wouldn't, I will follow this again. I will convince you in colorectal. Yes. Sometimes the practice you are internally reassured when you leave a drain, but that's not the if you search any and you can share together, you can have a speak together. So this is another collaborative research collab collaborative have given us idea about uh the intraperitoneal dream placement and the outcomes after elective colorectal surgery. This is a big core study called Compos uh complicated intra-abdominal collections after colorectal surgery. So it's a a prospective International Co study. They have how many patients say again, less debate about these operations? Less than the Yes, yes, because the, and the colorectal surgeries. The elective ones, there are two indications or there are two things that you might need to leave a drink for as we said, the bleeding. If you suspect bleeding, you have to stop it and you are thinking about a leak, le usually happen between three or five days post and you usually take the day before that. So exactly, there is no point. Exactly. So if you look at these parameters quickly, this is I need you to look in this one and this in this one because there is some, there are indications and some prophylactic stuff. If you look at any parameter here, surgical site infection, you will find it more. When we leave a drain, surgical site, infection at the drain site, you will find it. They not recorded when there is no drain because there is no drain. Uh Exactly, postoperative intra-abdominal collection, you will find it more on the other side. When you leave a drain, even a collection that you are poking a drain for it is the occurrence is more and this is larger study. Uh compas study postoperative major complications. There is uh also larger when you leave a drain discharge, you leave your length, hospital stay length will be more when you leave a dream. Ok. This is a good study and it is on um uh yeah, this is actually intra-abdominal for prophylaxis for anastomotic leak because again, some will say, oh, but because of the anastomotic leak, we will leave the train. And again, this is not true. There is no, the, the, the second study actually is um where is the PCOS? The rules? No. Yes. Oh, this is um anyway, there is another study that there is no statistically significant difference in an in participants treated with a prophylactic drainage or intraabdominal drain. Ok. So rains again as Fareed and bonus and Tabi and all of these were agreed that it is a sale of surgeon's preference and not substitute for good surgical practice. For example, Fareed answered us about make sure that he stays in. Ensure, make sure that there is no no retained fecalith and appendectomy. As GI said, there is no, you have done your washout and the washout is not always like copious, not always because there are some studies saying that when you have infection localized in a, in a, in a place, please do limit it washout. Don't spread the infection for anastomotic leak. If our consultants will agree, we need to make sure that the anastomosis is of good, of good blood supply, gentle handling of the tissues and of less tension. Ok. And lastly, you can leave a grain and you have circulation. Ok. So drain does not mean that you are safe and you are monitoring your collection. That's not true. Ok. Drain fixation. Quickly. There are a royal college study about how to fix a drain. And there are, they selected about five methods. One method is Centurion sandal with two lock, the plastic thighs and the other ones cent interior sandal with the steristrips and Centurion sandal with drain fixation just as we do uh in our trusts. And the other one is double loop method. And the other, this one is multiple loom method. They found that this uh they have increased our confidence that we, our method of cent standard method is uh safe and is recommended. So it was a new study and they said that if you need to read the later on, but they, our study, we have this, if you need to fix a drink, this actually is the nicest way and safest way and I like it if you would like to. Ok. So this is a different, I have seen no one do this, but it is very nice if you need to fix a drain. By the way guys, uh if you want to see basic surgical skit behind the knife is brilliant. We have very good detail. Excellent. Yes, I do agree. Yes, you cut the needle to be safe because otherwise it's not safe. And then you have your don't take too much. Exactly. Yes, because it, it would cause pain to the patient but make it too is because if it's a small drain and it's very loose, actually, the drain may pull for too loud while being fixated. So the inside that may pull out by the. So you have two limbs here, you start by the left side limb. You do this method twice. Ok. Please try this method today if you like because I will try it for the first time with you as well. OK. In right limb do the same from under the, from, from down to up. And that's it. Have you attended this video before? No, that's not the, is that the, uh I, I would say this is a double loop. I usually do the standard method. OK? We can so fat can show us how to do standard method as well. OK. And these are list of references and please, if you like, you can watch er, mechanism of mum mummification on National Geographic is very nice. Thank you so much. Um uh