Brief Communication: Removal of a Fractured Jackson-Pratt Drain Using Computerized Tomography-Guided Wire Localization
Surgical drain fracture is a rare but vexing postoperative complication. Drains provide egress of fluid and assist in tissue coaptation in deep soft-tissue wounds. During removal, a Jackson-Pratt (JP) drain may fracture if it is curled, pinched, over stretched, or inadvertently sutured. The fractured drain remains in situ, providing a nidus for infection. In order to remove the drain, surgeons historically re-explored the operative site, because the drain was difficult to locate by inspection or palpation. Re-exploration disrupts the healing wound and may increase recovery time. The difficulty of the retrieval is proportional to the depth of the drain.
Postoperative care of surgically repaired sacral decubiti involves appropriate wound care and complete rest for six weeks with or without air-fluidized beds.[4,5] This extensive period of healing without disruption would be interrupted by “blind” re-exploration, leading to an even lengthier recovery period.
Modern techniques, such as computerized tomography (CT)-guided wire localization, have made it possible to pinpoint precise anatomic locations in three dimensions that can then be easily identified intra-operatively. This technique has been used extensively in the diagnosis and treatment of breast, head, and neck lesions. It increases localization accuracy and minimizes the access incision needed to locate the surgical specimen. The authors suggest that CT-guided wire localization may be used to identify and assist in the removal of foreign bodies, such as fractured drains.
A 42-year-old paraplegic man presented with a stage 4 decubitus ulcer of the sacrum. The patient was planned for a surgical reconstruction with a unilateral V-to-Y gluteal flap followed by low-pressure bed treatment for an extended six-week period. After resection of the associated sacral decubitus ulcer with a resection of associated superficially necrotic bone, two deep drains were placed deep to the V-to-Y gluteal advancement flap. During the first four weeks, although the flap healed well, there was a persistent drainage of fluid that required continuous suction for four weeks. At this time, an attempt was made to remove one of the deep drains in the inferior base of the wound. (Figure 1). The drain was removed with difficulty. On examining the drain, it was found that the drain had fractured leaving an unknown length of drain in the wound. As the patient was already four weeks into a six-week program of pressure-reducing therapy in the low-pressure bed, it was decided that re-exploration of the wound would be detrimental to healing. Therefore, the patient was sent for a CT-needle-guided localization of the lost portion of the drain. The needle was guided through the previous incision site down to the deep portion of the wound, which was 7cm deep (Figure 2). This localization allowed precise orientation of the lost segment with regards to both depth and medial-to-lateral position. Using a 2.5cm minimal incision along the guide wire, the lost portion of the associated drain was removed without violating the entire flap. The patient then completed an additional two and a half weeks of low-pressure bed therapy. The wound healed without complication despite the additional opening up of the 2.5cm access site.
The removal of an iatrogenic-retained foreign body represents a difficult postsurgical complication. The foreign body must be removed in order to prevent infection and to permit adequate wound healing. Historically, the wound and the drain site were re-opened, explored, and the drain removed. The trauma to the surrounding tissue delayed wound healing and delayed patient recovery time. The goals for removal of a retained surgical drain should be removal of the retained segment in toto with minimal disruption of the healing tissue. The tenuous nature of the tissue following flap repair for sacral pressure sores necessitates minimal disruption.
There have been several case reports of fractured drains being removed with minimally invasive techniques. In one report, two fractured Penrose drains were removed from the retroperitoneal space and retrovesical space using fluoroscopic guidance and a surgical hemostat passed through a patent drain tract. In addition, two retained Jackson-Pratt drains have been retrieved using endoscopic techniques, a grasping forceps in one case and a Fogarty balloon in the second case. In this case, neither a fistula nor a patent drain tract was noted, rendering removal via either of the above means unfeasible.
CT-guided wire localization has also been used as an intra-operative tool to guide surgical dissection in the head and neck. In one case report, CT guidance allowed minimal and safe dissection with accurate localization and removal of a suspicious mass adjacent to the carotid artery. The neck had undergone a prior operation and irradiation, making the anatomy uncertain and traditional dissection dangerous. In another report, a foreign body was identified adjacent to the cervical spinal cord. Intra-operative palpation of tissue during “blind” surgical exploration would have endangered the patient. CT-guided wire localization allowed accurate dissection without collateral damage.
In this case, the retained drain segment was easily identified under CT, and a hook wire guide was introduced. The wire guide permitted use of a small 2.5cm access incision while increasing localization accuracy. The patient recovered post-operatively without incident and spent two and a half weeks on the low-pressure bed for a total of six and a half weeks, which was one half of a week more than originally planned. There was no adverse effect on the original flap repair and only a minimal increase in recovery time. This case illustrates an innovative application of a minimally invasive technique.