
















































JSSN_vol25i2-cut.pdf


www.jssn.org.npJournal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2) 40

Abstract

Ethical Clearance:

Financial aid:

Authors retain copyright and grant the journal right 

journal.

Indications and Outcomes of Abdominal Drain in Laparoscopic 
Cholecystectomy in a Tertiary Care Center in Central Nepal: A 
Descriptive Cross-sectional Study

Introduction
choice for symptomatic cholelithiasis. During this procedure, sometimes 
abdominal drain is placed in the right sub-hepatic space. The main 
objectives of this study were to assess the indications for the use of intra-

LCs.

Methods: This is a prospective descriptive cross-sectional study 

Department of Surgery of a tertiary level teaching hospital in Kathmandu, 

of intra-abdominal drain were selected for the study. The data were 

Results

the most common intraoperative indication for IAD in LC. Surgical site 

of the patients respectively. SSI was found to have a positive correlation 

Conclusion: The prevalence of IAD placement in LC in our study was 
almost double as compared to that of studies in other countries and 
predominantly more among males than females. Cholelithiasis with 
cholecystitis and adhesions were the most common indications for IAD 
placement. SSI in IAD placement was found to be positively correlated 
with the operative time, post-operative hospital-stay and age of the 
patient.

Keywords: Fever; hospital stay; intra-abdominal drain; laparoscopic 
cholecystectomy; operative time; post-operative; surgical site infection

None

None

Taken

Original article

Sandeep Khanal

Email: drsandeep@gmail.com

Khanal S. Indications and outcomes 
of abdominal drain in laparoscopic 
cholecystectomy in a tertiary care center in 
central Nepal: a descriptive cross sectional 

Dr. Sandeep Khanal,
Rapti Academy of Health Sciences,
Department of Surgery
Dang, Nepal

 
Rapti Academy of Health Sciences,
Department of Surgery
Dang, Nepal



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
41

Introduction 
Cholelithiasis is the most common biliary pathology seen 
in the out-patient department.1 Its prevalence ranges from 

2,3 Among the younger age 

women than in men.4
is the treatment of choice for symptomatic cholelithiasis.
Prophylactic polyethylene drain placement in the 
gallbladder bed in the subhepatic space has been practiced 
widely, with the dictum of Lawson Tait, the 19th century 

either to detect early complications, such as postoperative 
hemorrhage or leakage, or to remove collections such as bile 
which could later be infected.  Some surgeons recommend 
the use of a short-term drain postoperatively based on 

during the operation and the accumulation of gas in the 
right sub-phrenic area often leads to shoulder pain.8,9 The 
value of surgical drainage in laparoscopic cholecystectomy 

10 

of randomized trials in open cholecystectomy.11 Its use 
in developing countries where alternative modalities like 
routine imaging studies or interventional radiology are not 
easily accessible, has not declined. 

the use of IADs in elective LCs and compare the outcomes 
of the IADs with an aim to know how much of a value 

country.

Methods
This was a descriptive cross-sectional study conducted 

Department of Surgery, Nepal Medical College Teaching 

center located in Kathmandu, at central Nepal. Ethical 

surgery residents and team.

undergoing other surgeries of abdominal cavity along with 

Apart from that all the patients with ultrasonographic 

LC followed by placement of the intra-abdominal drain 
during the duration of study were selected. Convenience 

sample for the study. In all the cases with drain placement a 

After the surgery, patients with abdominal drain were 

with IAD placement, we listed out parameters like surgical 

comparison of these variables was done to look for any 

analysis was done by Statistical Package for Social Sciences 

with t-test and p-value < 0.05 was considered statistically 

Results

predominantly more among males as compared to females. 
The mean age of the patients undergoing IAD placement in 
LC was found to be 48±11.02 years. 

The majority of the patients were of the age group of 41 

elective LC with placement of IAD was 55 ± 9.8 minutes 

The most common preoperative indication for which 
IAD placement had to be done was cholelithiasis with 

included symptomatic cholelithiasis with cholesterolosis 

Table 1

Table 1. Preoperative indications for putting an abdominal 
drain in elective LC in patients with cholelithiasis.
Indications Frequency %
Cholelithiasis with cholecystitis 21 35.0
Cholelithiasis with empyema 
gallbladder

10

Cholelithiasis with gallbladder 
polyp

13

Symptomatic cholelithiasis with 
cholesterosis
Total 100.0



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
42

The most common intraoperative indication for drain 

Figure 
1
encountered were suspicious of bile leak, unsecured cystic 
duct closure, subtotal cholecystectomy or uncontrolled 
spillage of pus in empyema for which drain had to be 
placed. Iatrogenic bleed included cases of vascular injury, 

bed bleed which was controlled intra-operatively but with 
suspicion of bleeding again postoperatively then IAD was 
placed.

the patients developed fever. The average post-operative 

hospital stay of more than 10 days. 

SSI was found to have a positive co-relation with the 

pathogens and a greater chance of breach of the aseptic 
technique in the procedure due to longer operative time 
Table 2

Table 3

Table 4

was obtained showing that as the patient ages, there were 

study. The drain was removed between 24 and 48 hours 

and mortality.

Discussion
The prevalence of IAD placement following LC in our 

to the hospital. Also majority were referred cases from 
other centers suspecting the case to be complicated due to 

in ultrasonogram or thick walled gallbladder.  In a study 
conducted by Ahmet et al in 2013 in Turkey, drain was 

12 In another study 

the patients undergoing laparoscopic surgery, out of which 
13 The prevalence of IAD 

Figure 1. Pie chart diagram showing intraoperative indications 
for drain insertion. 

     Duration of surgery Total P-value

<30 
mins mins mins

Surgical 
Site 
Infection

No 2 2 51 0.01

Yes 0 2 9

Total 2 4 60

Table 2. Correlation between SSI and duration of surgery

Table 3. Correlation between surgical site infection (SSI) and 
fever in post-operative day following IAD for LC

Surgical Site 
Infection

Total P-value

No Yes
Fever No 49 8

Yes 2 1 3
Total 9 60

Table 4. Correlation between surgical site infection and 
postoperative hospital stay 

Post-operative 
hospital-stay

Total P-value

<5 
days

5-10 
days

>10 
days

Surgical site 
infection

No 20 31 0 51 0.003
Yes 2 5 2 9

Total 22 36 2 60

of patients
Age group Total P-value
<20 
yrs

20-40 
yrs yrs yrs

Surgical 
site 
infection

Yes 1 0 2 9 0.021
No 0 14 33 4 51

Total 1 14 39 6 60

Khanal S



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
43

placement after LC in our study is thus comparable to other 
studies done in other developing countries. 

Though in our study, more females underwent LC as 

were found more likely to have abdominal drain placed 

males having an IAD placed.14 In another study by Ahmet 

it did not specify the percentage or gender distribution of 
patients with IAD placement after LC.12 

The majority of the patients who underwent LC with 

12 In another study by 
Eun Young Kim et al in 2015, the average age of patients 
undergoing LC with IAD placement in Japanese population 

15 

A similar study by Bajracharya et al conducted in Nepal 
showed that the average age of patients was 41.30 years 

14

The most common indication for placing an abdominal drain 
in our study was cholelithiasis with cholecystitis followed 
by symptomatic cholelithiasis with cholesterolosis, 
cholelithiasis with gallbladder polyp and cholelithiasis 
with gallbladder empyema. In a study by Kumar et al done 
in 2012, the main indications for elective LC were acutely 

 In a study by Corwin et al 
done in 2011, out of 42 patients who went LC, the presence 
of gallbladder polyps with cholelithiasis was found to be 

 

The average operative time required for LC with IAD 
placement in our study was found to be 55 ± 9.8 minutes 
ranging from 30 to 80 minutes. Though the surgical 
approach and operating team were same for all the patients, 
variation in operative time could be due to the anesthesia 
time, minor variations in Calot’s anatomy. In a similar study 
by Sharma et al, the average time required for the operation 

3 In the study by Eun Young Kim et al 
in Japanese population, the operative time recorded on 

15 

The most common intraoperative indication for drain 

a similar study by Hussain et al,      the indications for placing 

18 In another 
study by Shamim et al, adhesion in Calot’s triangle was 

19 

El-labban et al in 2012, IAD in LC was associated with 
20 In a similar study done by 

with IAD placement. 21 Both the studies show comparative 
results with our study. The reason for our prevalence being 
slightly lower is probably due to a smaller number of cases 
in our study. 

none of the patients having high grade fever with chills or 

study of patients with IAD after LC, conducted by Chauhan 
22 In another similar study done by Shamim 

19 
The comparisons between these studies do not show much 

The average postoperative hospital stay in our study was 

al, the mean duration of post-operative hospitalization was 
4±2.9 days.12 This study also showed that the placement of 
drain prolonged postoperative hospital stay when compared 
with patients without IAD placement after LC. In another 
study by Singh et al, the average duration of postoperative 

days.21 These comparisons show that the median duration 
of hospital day postoperatively with IAD placement after 
LC is slightly higher in developing countries. 

association was found in a study done by Chen et al which 

operative time and SSI, with close to twice the likelihood 
of SSI being observed across various time thresholds i.e., 

patients with SSIs.23

24 This positive association was probably 

and a greater chance of breach of the aseptic technique in 
the procedure due to a longer operative time.

SSI was also compared with fever which showed a negative 

are introduced at the time of the operative procedure from 
25 However, fever was 



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
44

infection.25

postoperative hospital stay as there was a positive 

surgical site infection and postoperative hospital stay. Thus, 

study by Mujagic et al conducted in Switzerland.

as the age of the patient increases, the patient has more 
chances of getting an SSI. In a similar study by Talbot et 
al, the relationship between age and the risk of surgical site 

 In 
another study by Kaye et al, increasing age independently 

The sheer volume of patients and procedures studied 

patients were included for analysis.28 This large sample 
size allowed for the study team not only to derive the 
relationship between age and risk of SSI but also to validate 

consistent with our study which is the strength of our study.

The limitations in our study was however it was done in 

and evaluated with outcomes comparison in studies of 
other developing countries. However we do not want to 
emphasize in putting a drain or not putting it. Drains should 
not be placed routinely after LC as it increases pain and 
does not help in detecting or decreasing complications.29,30

Conclusion 
The prevalence of IAD placement in LC in our study is 
almost double as compared to similar studies done in 
other countries which could be due to limited resources. 
It was predominantly more among males.  Cholelithiasis 
with cholecystitis and adhesions were respectively the 
most common elective and intra-operative indications for 
IAD placement in LC. SSI and fever were encountered 
respectively only in a small fraction of the patients. SSI 

operative time, post-operative hospital-stay and age of the 
patient. It may not be wise put the drain in very advanced 
hospital setup. However in developing countries like 

indications of IAD in LC and association of the outcomes 
was quite similar on comparison with other studies in 
various countries. 

References

1. 

Biological Basis of Modern Surgical Practice. 18th 

2. National Institute of Health Consensus 

and Laparoscopic Cholecystectomy. Amer J Surg. 

3. 
after Elective Laparoscopic Cholecystectomy. 

4. 
M, Dolapci M. A risk score for conversion from 
laparoscopic to open cholecystectomy. Am J Surg. 

5. 

laparoscopic cholecystectomy to open surgery. Surg 

8. 

9. 

low-pressure pneumoperitoneum for reduction of 
shoulder-tip pain following laparoscopy. Br J Surg. 

10. 
decision for conversion of laparoscopic to open 
cholecystectomy for treatment of acute cholecystitis. 

11. 
indications for elective cholecystectomy for 

12. 

13. 

14. Bajracharya A, Adhikary S, Agarwal CS. 

of university hospital in eastern Nepal. Health 

Khanal S



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
45

15. Kim EY, Lee SH, Lee JS, Yoon YC, Park SK, Choi 
HJ. Is routine drain insertion after laparoscopic 

A multicenter, prospective randomized controlled 

Kumar DL. Laparoscopic Cholecystectomy vs. 

51.

Incidentally detected gallbladder polyps: is follow-

18. 

19. Shamim M, Memon AS, Bhutto AA, Dahri MM. 

cholecystectomy in a tertiary care institution. J Pak 

20. 
A, Heissam K, El-Kammash S. Laparoscopic 
elective cholecystectomy with and without drain: A 
controlled randomised trial. J Minim Access Surg. 
2012; 8:90-2.

21. Singh M, Singh K, Chawla IS. Laparoscopic 
cholecystectomy with and without drainage - a 

22. 

following elective laparoscopic cholecystectomy be 

A prospective randomised study. J Minim Access 

23. 

24. 
ADM, Ercole FF. Incidence and risk factors for 

25. 

of surgical drains with surgical site infections - A 
prospective observational study. Am J Surg. 2019 

and the risk of surgical site infection: a contemporary 

2005 Apr 1; 191:1032-5.
28. 

the risk for surgical site infection. J Infect Dis. 2005; 

29. 

cholecystectomy in acute calculous cholecystitis: a 
randomised controlled study. Postgrad Med J. 2020 

30. 




