Fundamental rule of thoracic surgery
In operative thoracic surgery, there is an immutable law: any intervention involving lung tissue must conclude with the placement of a drainage system. The primary condition is that drains must be placed strictly before the surgeon begins to close the chest wall. This ensures system tightness and proper functioning of the pleural cavity in the postoperative period. The choice of technique, number of tubes, and their operating mode directly depend on the extent of the resection performed.
Drainage after pneumonectomy
Pneumonectomy (complete removal of the lung) requires a specific approach to the evacuation of contents.
- Quantity and type: Exactly one valve drainage tube is installed. It often operates in a passive outflow mode or is periodically clamped.
- Localization: The tube is brought out into the 8th intercostal space strictly along the posterior axillary line.
- Technical equipment: The outer end of the drainage tube must be immersed in a special vessel filled with an antiseptic.
- Valve design: In clinical practice, the valve mechanism can be formed using improvised means. For example, a regular finger from a surgical rubber glove with a small incision made at the end is successfully used for this purpose.
The main goal of such passive drainage is strict control over the accumulating exudate and, critically, the maintenance of the correct position (alignment) of the mediastinal organs.
Drainage after partial lung resection
Partial resections, such as lobectomy (removal of a lobe) or segmentectomy (removal of a segment), fundamentally change the management strategy for the pleural cavity. The remaining part of the lung must expand, which requires a completely different mode of air and fluid evacuation.
- Number of tubes: In this case, two drains are installed. A mandatory requirement for them is the presence of multiple side holes for maximum capture of the discharge.
- Topography of placement:
- The first drain is placed along the posterior surface of the thoracic cavity.
- The second drain is located along the anterior surface.
- Operating mode: Unlike pneumonectomy, this exclusively utilizes a continuous active suction (aspiration) system.
The two active tube setup allows for the fastest and most efficient evacuation of both air and accumulating fluid, ensuring the expansion of the remaining lung tissue.
Briefly: answers to topical questions
What requirements apply to the design of drainage tubes installed after partial lung resection?
After partial lung resection (lobectomy or segmentectomy), drainage tubes with multiple side holes are used. Two such drains must be installed: one placed along the posterior surface of the thoracic cavity and the second along the anterior surface. Both drains must be connected to a continuous active suction system for efficient aspiration.
What surgical instruments are included in the standard set for pleural drainage placement?
A scalpel, a wide trocar, and the drainage tube itself are used for pleural drainage placement. The skin is incised with the scalpel, after which the intercostal space is punctured with the wide trocar. The drainage tube is inserted directly through the trocar cannula, which is then removed. Suture material or an adhesive plaster strip is used to secure the tube to the skin.
What is the classic Bülau technique for pleural cavity drainage?
The classic Bülau passive drainage technique involves using an underwater valve that prevents the backflow of air or fluid into the pleural cavity.
- Valve — a finger from a rubber glove with an incised tip is placed on the end of the drainage tube.
- Antiseptic barrier — the tube with the valve is submerged in a jar of antiseptic solution.
The mechanism of action is based on the fact that the valve allows pus and air to pass freely outward, while during inspiration, when negative pressure is created, it collapses and seals tightly.
What intraoperative complications can occur directly during the placement of a drain in the pleural cavity?
Directly during the puncture of the chest wall for access to the pleural cavity, the following intraoperative complications may occur:
- Damage to internal organs — the risk of injuring the lung, diaphragm, liver, spleen, or stomach in case of instrumental insertion errors.
- Damage to the neurovascular bundle — occurs when the puncture point is chosen incorrectly (not along the upper edge of the underlying rib).
- Pneumothorax or pyopneumothorax — develops when atmospheric air enters the cavity due to system depressurization.
What are the objective clinical and radiological criteria for removing a drain from the pleural cavity?
The sources provide pleural drainage removal criteria for specific clinical situations.
In children with pneumothorax:
- absence of air bubbling for more than 24 hours;
- lung expansion according to radiography data.
In adults with hemothorax:
- absence of air leak;
- absence of radiological signs of coagulated hemothorax;
- exudation volume less than 200 ml/day.
For quick memorization of the number of drains: "Removed the whole lung (1 organ) — place 1 drain for monitoring. Removed a part (tissue remains) — place 2 drains (front and back) for active assistance".
Class and exam questions
What solution must the tube be immersed in when forming a valve drain?
The tube must be immersed in a vessel filled with an antiseptic.
What is the exact localization of the single drain after pneumonectomy?
It is placed in the 8th intercostal space along the posterior axillary line.
What operating mode of the drainage system is indicated after lobectomy and segmentectomy?
Both installed drains must be connected to a continuous active suction (aspiration) system.
What is the simplest way to make a valve for a drain?
A finger from a rubber glove with an incised tip can be used.
What else to study on this topic
- Anatomic landmarks: intercostal spaces and axillary lines
- Physiology of mediastinal alignment after lung resection
- Mechanics of continuous active suction (aspiration)
- Differences between exudate and air in the pleural cavity
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