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.