Wednesday, April 23, 2008
I must admit I have a Jackson-Pratt fetish. No, it isn't as sordid as it sounds. I just love leaving these babies inside the human body (in the appropriate clinical scenario, of course). Nothing helps a frazzled general surgeon sleep better at night after a tough, dicey case than knowing you've left a drain behind.
What's a Jackson-Pratt (JP)?
A closed suction, silastic tube with multiple perforations on the flat part that resides in the body. You can attach it to a bulb which applies a constant negative pressure to the intracorporeal portion of the tubing.
What purpose do they serve?
Helps evacuate fluid/blood/pus from spaces in the body.
When do you decide to leave one?
-Lap appy for perforated/gangrenous appendicitis
-Nasty gallbladders with spillage of foul bile during a lap chole
-If there are common duct stones seen on a cholangiogram and I can't clear the duct laparoscopically; higher risk of the clips coming off from elevated ductal pressure.
-Emergency lap chole on a patient on plavix/aspirin, or even if the liver bed looks a little "oozy". Gives you an idea of any "bright red" blood loss.
-Next to low colorectal anastomoses
-Most pancreatic surgery
-Patients who present with peritonitis and massive fecal contamination
-After mastectomies/axillary dissections
-After excision of large lipomas (dead space can fill with serous fluid)
-Under the flaps after a large open ventral hernia repair
-Those cases where I just sorta feel like it.....
Now you don't want to stick a JP in the belly after every case. They provide a route for skin bacteria to enter the abdomen and cause abscesses. The closed suction design makes this less likely compared to say, the Penrose drain, but you have to be careful nonetheless. There is good literature to suggest that leaving a drain in after splenectomy will lead to higher rates of infectious complications. Also, you have to be careful leaving drains in too long around a fresh anastomosis. Sometimes the JP can erode into healing bowel and cause a fistula. I've even had a patient yank at the JP and snap it off flush at the skin surface, and have to go back in to retrieve the tip laparoscopically.
When do you take out a JP?
Depends. Breast drains I leave in until daily outputs are consistently less than 30cc a day. Most JP's left in after gallbladder surgery come out the next day unless I'm waiting for an ERCP to be done. Drains left after complicated cases of perforated appendicitis usually come out in a day or two. It's a judgment call for the most part.
Does it hurt?
A bit. Usually not much at all, and it comes out fast.
Going home with a JP happens occasionally, especially in breast and pancreatic surgery. They're not too difficult to care for; patients receive teaching from nursing staff and me prior to discharge, and are instructed to measure daily outputs. I usually send them home with a JP instruction packet, something like this.