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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 46-51

Routine subcutaneous drains versus no drains in repeated elective and emergent cesarean sections


Department of Obstetrics and Gynecology, Menoufia University, Menoufia, Egypt

Date of Submission01-Feb-2017
Date of Acceptance03-May-2017
Date of Web Publication14-Jun-2018

Correspondence Address:
Mohamed T. Abd Al-Rahman Khalaf Allah
Department of Obstetrics and Gynecology, Menoufia University, Shebin Al-Kom, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_14_17

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  Abstract 


Objective
The aim of this study was to determine whether the routine use of subcutaneous drains can reduce the wound complications following cesarean section(CS).
Background
CS is one of the most common operative procedures performed in modern obstetrics. One of the most common complications of CS is surgical site complications, including infection, seroma formation, and disruption. One of the common, yet debatable, practices in CS is the use of a subcutaneous drain for the wound.
Patients and methods
This is a randomized controlled study that was conducted at the obstetrics and gynecology department, Menoufia university hospitals. The study included 200patients who were subjected to CS. They were divided into two groups: group1, which included patients in whom a subcutaneous drain was used, and group2, which included patients in whom no subcutaneous drain was used. The duration of surgery and the duration of hospital stay were recorded. The patients were followed up and the following complications were assessed: wound infection, wound seroma, wound disruption, postoperative pain, and postoperative fever.
Results
Use of subcutaneous drains significantly reduced wound seroma(21% in the no drain group and 3% in the drain group), wound disruption(38% in the no drain group and 9% in the drain group), the need for redressing(41% in the no drain group and 12% in the drain group), and postoperative pain(a mean±SD of 5.4±0.9 in the no drain group and 2.76±1.17 in the drain group). There was no significant difference as regards wound infection or the duration of postoperative hospital stay.
Conclusion
We found that the routine use of subcutaneous drain for lean women undergoing CS can only reduce wound seroma, wound disruption, postoperative pain, and the need for redressing. However, there was no added benefit as regards other wound complications such as wound infection and postoperative fever.

Keywords: cesarean section, subcutaneous drains, wound complications


How to cite this article:
Fahmi MM, Hamza HA, S. El-Nasr IA, Khalaf Allah MT. Routine subcutaneous drains versus no drains in repeated elective and emergent cesarean sections. Menoufia Med J 2018;31:46-51

How to cite this URL:
Fahmi MM, Hamza HA, S. El-Nasr IA, Khalaf Allah MT. Routine subcutaneous drains versus no drains in repeated elective and emergent cesarean sections. Menoufia Med J [serial online] 2018 [cited 2018 Aug 17];31:46-51. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/46/234206




  Introduction Top


Cesarean section(CS) is one of the most common operative procedures performed in modern obstetrics [1]. Despite that, surgical techniques and steps do widely vary [2]. These variations depend on many factors, which include surgeon's preferences, patient's characteristics, and available facilities and circumstances [3].

One of the most common complications of CS is superficial surgical site complications, including sepsis, seroma formation, and breakdown [4].

One of the common, yet debatable, practices in CS is the use of a subcutaneous drain for the wound. The advantage of such a practice is that any blood or serous fluid that may accumulate in the subcutaneous space, which causes postoperative pain or provides a good medium for microbial growth and infection, can be drained [5].

Thus, it is assumed that drains can reduce the burden of surgical site infection. Some surgeons, however, have raised much argument about the value of subcutaneous drains [5].

Despite this, it is evident that it is still widely used in the clinical practice [2].

In this study, we aimed at providing answers for this critical issue so as to provide the best quality of care following CS.


  Patients and Methods Top


This study is a randomizedcontrolledstudy conducted at the Department of Obstetrics and Gynecology, Menoufia University hospitals, from December 2015 to December 2016.

Patients were randomly allocated to the drain or the no drain group. Randomization to two groups was carried out using computer-generated numbers with 1:1 ratio. Patient names were hidden and replaced by numbers. Allocation was conducted using the sealed envelopes method and was only opened after uterine closure.

Approval from the Ethical Committee of the Faculty of Medicine, Menoufia University, was obtained before the commencement of the study. The study included 200 women with previous CSs who were admitted in the Department of Obstetrics and Gynecology at Menoufia University hospitals for elective or emergent CS. To control any confounding variables, we excluded women with an added risk for wound complications. The following patients were excluded from the study:

  • Diabetic women(determined by fasting and 2-h postprandial blood glucose)
  • Obese women(defined in our study as those with BMI more than 25kg/m 2) in the booking visit (if recorded in her antenatal care record), but if not recorded, we excluded women with BMI more than 25kg/m 2 on admission
  • Smokers and alcoholics
  • Immunocompromised women: AIDS patients and those receiving immunosuppressant agents.


Patients were divided into two groups.

Group1(100patients) included patients to whom repeated CS was performed with insertion of subcutaneous drain.

Group2(100patients) included patients to whom repeated CS was performed without insertion of subcutaneous drain.

Preoperative evaluation

Preoperative evaluation included thorough history taking, general examination, and obstetric examination.

Preoperative investigations were carried out for all patients.

Surgical technique

Type of anesthesia: spinal anesthesia was induced for patients.

A standard surgical technique was performed. The maximum thickness of the subcutaneous tissue was measured in centimeters before we entered the peritoneal cavity. Asingle dose of antibiotic prophylaxis of 2g of intravenous cefazolin was administered to each woman after umbilical cord clamping. The lower segment uterine incision was closed in two layers with continuous synthetic absorbable vicryl 1 suture(Polysorb; Dublin, Republic of Ireland). The peritoneum was not closed. The rectus sheath was sutured using continuous absorbable synthetic vicryl 1 suture(Polysorb). In the drain group, a closed nonvacuum drain(ArabMedical Industry, Borg El Arab, Alexandria, Egypt) was inserted in the subcutaneous tissue and exited from the skin through a separate opening and stitched to the skin. The subcutaneous tissue was not sutured. Cautery was used for hemostasis. The skin was closed with a continuous nonabsorbable polypropylene 2/0(Acufirm; Ernst Kratz, Germany) subcuticular sutures. Operative time was estimated from the start of skin incision until the end of skin suturing. The drain was left until the drainage rate was less than 50ml/day. All procedures were performed by the same team.

Postoperative assessment

All patients were subjected to follow-up during postoperative stay in Menoufia Hospital to be followed up with regard to postoperative pain, postoperative fever, hospital stay duration, wound infection, wound seroma, wound disruption, and the need for redressing. The postoperative pain was judged after 24h using visual analogue scale(VAS), which is a continuous scale that is 10cm(100mm) in length. Postoperativepain intensity is described as follows on the pain VAS: no pain, 0–4mm, mild pain, 5–44mm; moderate pain, 45–74mm; and severe pain, 75–100mm.

All women were given ketorolac tromethamine(Ketolac, Amriya pharm industries, Alexandria, Egypt) 30mg, intramuscularly, ampoule/6 hfor the first 24h.

Patients were discharged from the hospital 24h after the surgery if there were no postoperative complications.

  • In the drain group, the drain was left until drainage rate was less than 50ml/day
  • Follow-up of patients was for 1week after the surgery in the Menoufia University Outpatient Clinic.


Statistical analysis

Data analysis was conducted using statistical package for the social sciences(SPSS, v. 22, IBM, Armonk, New York, United States) program. Student's t-test and analysis of variance was used to compare the mean wound infection(or other outcomes) among different groups. The χ2 test was used to compare categorical variables and a P value less than 0.05 was considered statistically significant in all these tests.


  Results Top


In the current study, 200patients, for whom repeated CS was performed, were divided into two groups; each group included 100patients.

In group1, subcutaneous drain was inserted, and in group2 a subcutaneous drain was not inserted.

There was no statistically significant difference between the two groups as regards age, parity, gravidity, gestational age, subcutaneous tissue thickness, and BMI[Table1].
Table 1: General characteristics of the studied group

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We assessed surgery duration in both groups and there was a significant statistical difference between the two groups. In the drain group, the mean was 47.05±5.2min and it was 43.5±4.8min in the no drain group(P=0.001)[Figure1].
Figure 1: Difference between the drain and no drain groups as regards the duration of surgery.

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As regards the duration of postoperative hospital stay, there was no significant statistical difference between the two groups. In the drain group, the mean was 2.5±1.9days and it was 2.4±2.3days in the no drain group(P=0.6)[Table2]).
Table 2: Comparison between the drain and no drain groups as regards the duration of surgery and postoperative hospital stay

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As regards postoperative wound complications, there was no significant statistical difference between the two groups as regards the rate of wound infection. The incidence was 9% in the drain group and 14% in the no drain group(P=0.24)[Figure2].
Figure 2: Difference between the drain and no drain groups as regards wound infection.

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Moreover, as regards postoperative fever, there was no significant statistical difference between the two groups. The incidence was 3% in the drain group and 6% in the no drain group(P=0.2)[Figure3] and [Table3].
Figure 3: Difference between the drain and no drain groups as regards the postoperative fever.

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Table 3: Comparison between the drain and no drain groups as regards wound infection and postoperative fever

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There was a significant statistical difference between the two groups as regards the rate of wound seroma. The incidence was 3% in the drain group and 21% in the no drain group(P=0.001)[Figure4].
Figure 4: Difference between the drain and no drain groups as regards the wound seroma.

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Moreover, as regards wound disruption, the incidence was 9% in the drain group and 38% in the no drain group(P=0.001). As regards the need for redressing, the incidence was 12% in the drain group and 41% in the no drain group(P=0.001)[Figure5] and [Table4].
Figure 5: Difference between the drain and no drain groups as regards wound disruption.

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Table 4: Comparison between the drain and no drain groups as regards wound seroma and disruption

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As regards postoperative pain, there was a significant statistical difference between the two groups. In the drain group the mean was 2.76±1.17, and it was 5.4±0.9 in the no drain group(P=0.01)[Table5].
Table 5: Comparison between the drain and no drain groups as regards postoperative pain

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  Discussion Top


In an era where the rate of cesarean delivery is rising, performance of optimal surgical techniques to minimize complications from cesarean delivery is of great clinical importance [3]. The use of prophylactic drain placement to prevent wound complication, however, is controversial and investigations that have evaluated its efficacy in this setting have reported conflicting results [4].

The present study was conducted to compare the outcomes of subcutaneous drainage versus no drainage in the wound complications after CS.

As regards the preoperative data in this study, there was no significant statistical difference between the two groups as regards age, gravidity, parity, BMI, and the subcutaneous tissue thickness to ascertain that the postoperative outcomes will be related mainly to the selected procedure.

Uniquely to our study, obese women were excluded, and hence all women were with BMI less than 25kg/m 2, and there was no significant statistical difference between the two groups as regards BMI of the participants, abolishing the effect of obesity on the outcomes.

Unlike our study, several studies did not exclude obese women. Khalifa etal. [6], in their randomized controlled study on 170 women, aimed to compare the effect of routine subcutaneous drain versus no drain on wound complications in CS for diabetic obese women [4]. The mean BMI was 34.1±1.9kg/m 2 in the drain group and 34.2±1.7kg/m 2 in the no drain group(P=0.1) [6]. Similarly, Magann etal. [3] conducted a randomized controlled study on 590 women to compare the effect of subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery. The mean BMI was 40.7±12.7kg/m 2 in the drain group and 39.4±8.6kg/m 2 in the no drain group(P=0.39) [3]. Others such as Ramsey etal. [7] performed a randomized controlled study that included 280 obese women to compare the effect of subcutaneous tissue approximation alone with subcutaneous tissue approximation in combination with a drain; no wound complications in obese women undergoing cesarean delivery were reported. The mean BMI was 48.0±11.4kg/m 2 in the drain group and 45.0±9.2kg/m 2 in the no drain group(P=0.019) [7].

Inour study, we found that the operation time was significantly shorter in the no drain group than in the drain group, which may be attributed to the time taken for the drain insertion and then exiting it from the skin through a separate opening and stitching it to the skin. We agree with Ochsenbein-Imhof etal. [8], who conducted a randomized controlled study on 305 women to determine the benefit of cesarean wound drainage in low-risk pregnant women. The mean was 43.5±4.8min in the no drain group and 47.1±5.2min in the drain group(P=0.001), and this was also attributed to the time consumed for drain insertion [8].

Other studies found no significant statistical difference as regards operative time. Magann etal. [3] reported a mean operative time of 45.1±18.2min in the no drain group and 46.8±19min in the drain group(P=0.6).

In our study, there was no significant statistical difference between the two groups as regards postoperative wound infection. In this perspective we agree with Khalifa etal. [6], who found that the drain group and the no drain group had comparable incidence of wound infection(6vs. 8%, respectively, P=0.6). Moreover, in the study by Magann etal. [3], wound infection was diagnosed in 7% of cases in the drain group and in 8% of cases in the no drain group(P=0.88). Al-Inany etal. [9], in their randomized controlled study on 120 women, aimed to determine whether closed subcutaneous drainage systems were efficacious in reducing the rate of wound breakdown of pfannenstiel incision after CS in obese women; they also could not demonstrate significant differences in the incidence of wound infection between the drain group and the no drain group(5vs. 12%, respectively, P=0.08) [9]. Allaire etal. [10] conducted a randomized controlled study on 76 women to determine whether subcutaneous drain decreases the incidence of wound complications in obese women undergoing cesarean delivery. They showed that there were no cases of wound infection in the drain compared with 4% in the no drain group, yet this difference was not significant(P=0.34) [10].

Our study showed that there was a significant statistical difference between the two groups as regards the rate of wound seroma. This high incidence in the no drain group may be attributed to the fact that in the no drain group we did not suture the subcutaneous tissue.

Other studies also showed this, such as the study by Khalifa etal. [6], who found that the incidence of wound seroma was 9% in the drain group and 23% in the no drain group(P=0.01).

Moreover, Kumar [11] in a randomized controlled study on 148 women to compare subcutaneous drain versus subcutaneous stitch closure to prevent wound disruption after CS showed a significant difference. The incidence of wound seroma was 0% in the drain group and 12% in the no drain group(P=0.02) [11].

Other studies did not show a significant difference between the two groups.

Allaire etal. [10] in their study reported that the incidence of wound seroma was 0% in the drain group and 12% in the no drain group(P=0.09). Moreover, Magann etal. [3] in their study reported that the incidence of wound seroma was 1.5% in the drain group and 3% in the no drain group(P=0.53). Ramsey etal. [7] found that the incidence of wound seroma was 10% in the drain group and 11% in the no drain group(P=0.55).

As regards wound disruption, our study showed that there was a significant statistical difference between the two groups as regards the rate of wound seroma (P=0.001). This high incidence in the no drain group may be attributed to the fact that in the no drain group we did not suture the subcutaneous tissue.

Kumar [11] also showed a significant difference. The incidence of wound disruption was 4% in the drain group and 20% in the no drain group(P=0.02).

Other studies showed a nonsignificant reduction, such as the study by Magann etal. [3], who reported that the incidence was 9% in the drain group and 10% in the no drain group(P=0.85). Moreover, Ramsey etal. [7] found that the incidence of wound disruption was 15% in the drain group and 22% in the no drain group(P=0.17).

As regards postoperative pain, our study showed that there was a significant statistical difference between the two groups(P=0.01).

Khalifa etal. [6] found that there was also a significant difference between the drain and no drain groups as regards the mean postoperative pain(P=0.01).

In the CAESAR trial(2010), a randomized controlled study on 3033 women to compare the effect of alternative surgical techniques on adverse outcomes, assessment of the postoperative pain at the time of hospital discharge and 6weeks after the CS was carried out, and there was no significant difference between the drain and no drain groups(P=0.2 and 0.1, respectively) [12].

Kumar [11] also used a 10cm VAS and found no significant difference between the drain and no drain groups(P=0.06).

As regards postoperative fever, our study showed that there was no significant statistical difference between the two groups(P=0.2).

Other studies also showed this, such as the study by Khalifa etal. [6], in which the incidence was 10% in the drain group and 15% in the no drain group(P=0.3). In CAESAR trial(2010), there was no significant statistical difference between the two groups but the incidence of febrile morbidity was about 1% in both groups, and this may be due to the difference in definition of febrile morbidity. Febrile morbidity was defined as temperature less than 39°C on any occasion, but in our study the rise in temperature more than 38°C after the first 24h postpartum was recorded [12].

As regards the duration of postoperative hospital stay, our study showed that there was no significant statistical difference between the two groups(P=0.6). We agree with other studies, such as the study by Ochsenbein-Imhof etal. [8], who reported that the duration was 0.9days less in the no drain group(P=0.7), and the CAESAR trial(2010) as the duration of hospital stay was 4.8+1.9days in the drain group and 4.7+1.8days in the no drain group(P=0.09) [12].

Uniquely to our study, the need for redressing was compared and showed that there was a significant statistical difference between the two groups (P=0.001).


  Conclusion Top


We found that the routine use of subcutaneous drain for lean women undergoing CS can only reduce wound seroma, wound disruption, postoperative pain, and the need of redressing. However, there was no added benefit as regards other wound complications such as wound infection and postoperative fever.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
GadMS, AbdMM, SttarE, AbdAM, GayedE, MahmoudNF. Evaluation of lower segment cesarean section scar by sonography. Menouf Med J 2015; 28:873–878.  Back to cited text no. 1
    
2.
HofmeyrGJ, MathaiM, ShahAN, NovikovaN. Techniques for caesarean section. Cochrane Database Syst Rev 2008; 1:CD004662.  Back to cited text no. 2
    
3.
MagannEF, ChauhanSP, Rodts-PalenikS, BufkinL, MartinJN, MorrisonJC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002; 186:1119–1123.  Back to cited text no. 3
    
4.
TullyL, GatesS, BrocklehurstP, McKenzie-McHargK, AyersS. Surgical techniques used during caesarean section operations: results of a national survey of practice in the UK. Eur J Obstet Gynecol Reprod Biol. 2002; 102:120–126.  Back to cited text no. 4
    
5.
GatesS, AndersonER. Wound drainage for caesarean section. Cochrane Database Syst Rev 2013; 13:CD004549.  Back to cited text no. 5
    
6.
KhalifaAAA, AbdelrazakKM, AbdelazimIA. Routine subcutaneous drain versus no drain in cesarean section for diabetic obese women: a randomized controlled trial. Int J Curr Microbiol Appl Sci 2015; 4:479–485.  Back to cited text no. 6
    
7.
RamseyPS, WhiteAM, GuinnDA, LuGC, RaminSM, DaviesJK, etal. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol 2005; 105(Part1):967–973.  Back to cited text no. 7
    
8.
Ochsenbein-ImhofN, HuchA, HuchR, ZimmermannR. No benefit from post-caesarean wound drainage. Swiss Med Wkly 2005; 131:246–250.  Back to cited text no. 8
    
9.
Al-InanyH, YoussefG, Abd El MaguidA, Abdel HamidM, NaguibA. Value of subcutaneous drainage system in obese females undergoing cesarean section using pfannenstiel incision. Gynecol Obstet Invest 2002; 53:75–78.  Back to cited text no. 9
    
10.
AllaireAD, FischJ, McMahonMJ. Subcutaneous drain vs. suture in obese women undergoing cesarean delivery. Aprospective, randomized trial. JReprod Med 2000; 45:327–331.  Back to cited text no. 10
    
11.
KumarSA. Subcutaneus drain versus subcutaneus stitch closure to prevent wound disruption after cesarean section. JObstet Gynaecol india. 2004; 54:237–242.  Back to cited text no. 11
    
12.
BrocklehurstP. Caesarean section surgical techniques: a randomised factorial trial(CAESAR). BJOG. 2010; 117:1366–1376.  Back to cited text no. 12
    


    Figures

  [Figure1], [Figure2], [Figure3], [Figure4], [Figure5]
 
 
    Tables

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