Hashemite University, Zarqa, Jordan.
Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland.
Langenbecks Arch Surg. 2024 Sep 5;409(1):271. doi: 10.1007/s00423-024-03459-w.
Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload.
Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed.
Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously.
The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.
引流管用于减少手术后腹部积液。自从开放手术时代以来，胆囊切除术后使用引流管一直存在争议。普遍接受的适应证和共识是常规引流是不必要的，但选择性引流的作用仍未确定。本研究评估了在一个具有大量胆道急诊工作量的专科单位中，在接受腹腔镜胆囊切除术（LC）和胆管探查术（BDE）的患者中肝下引流的适应证和益处。
回顾性分析了 30 年来 6140 例 LC 的前瞻性收集数据，其中急诊工作量为 46.6%。比较了有和无引流管的患者的人口统计学因素、术前表现、影像学和手术细节。所有经胆管探查、次全胆囊切除术、几乎所有开腹中转手术和 94%的积脓 LC 术后均放置肝下引流管。分析术后与引流管相关的不良或有益结局。
在 6140 例患者中，有 3225 例（52.5%）使用了引流管。患者年龄较大，男性比例较高。59.4%为急诊入院。术前影像学显示 25.2%的胆囊壁厚，36.2%的胆管结石或扩张。术中发现胆囊管结石 19.8%，急性胆囊炎、积脓或粘液囊肿 28.4%，手术难度分级 III 级或以上 59%。38%的患者行 BDE，5.4%行底部-first 解剖，手术时间较长（80 分钟 vs.45 分钟）。引流管相关并发症罕见；3 例麻醉恢复后腹痛，引流管拔除后缓解，2 例引流部位感染，1 例再腹腔镜取出回缩引流管。43 例有胆汁漏的患者中，55.8%和 20 例有其他积液的患者中，35%的患者自行解决。
由于高急诊工作量和对 BDE 的兴趣，本研究中引流管的使用相对较高。虽然引流管可以早期发现胆漏，避免一些并发症，并监测保守治疗以允许早期再次干预，但该研究已经确定了可能通过选择性政策限制引流管插入的手术标准。
