238Surgical Devices

DRAINS

•   Gastric tube (G-tube): indicated for decompression of the stomach to avoid long-term use of a nasogastric tube. It can also be used for feeding patients with swallowing difficulties. When placed to gravity, it can be used as an outlet for bowel contents to decrease nausea and vomiting in patients with bowel obstruction.

•   Chest tube: indicated for pleural effusions, hemothorax, or pneumothorax (if >15%). When used with pleurovac, negative pressure is set at 20 cm of H₂O. A purse string stitch is placed subcutaneously to secure it to the skin. Petrolatum-impregnated gauze should be placed over the incision to make it airtight. Obtain CXR daily.

        Pneumothorax: place to suction for 2 days, then to water seal for the third day. A CXR should be obtained daily to evaluate size of pneumothorax. Leave water sealed until the output is less than 100 mL in 24 hours, and check for the presence of an air leak daily. Pull the CT when the pneumothorax is <10%, when output is less than 100 mL in 24 hours and there is no air leak.

        Hemothorax or pleural effusion: place to suction for 1 day and then to water seal for the second day. Pull when output is less than 100 mL in 24 hours.

        Resolution normally occurs at 10% to 20% per day.

        When it is ready to be pulled, the patient should take a deep breath and then Valsalva. The tube is then pulled out as the purse string stitch is secured tightly around the prior incision. A petrolatum gauze should be placed on top.

•   Jackson-Pratt: indicated for subcutaneous or intraperitoneal wound drainage. Used to decrease the incidence of seroma and infection. It is a closed drain; placed to bulb suction.

        Subcutaneous: removal is recommended when output is less than 30 mL per day. Subcutaneous drainage decreases the incidence of seromas and infections if not used in conjunction with a subcutaneous stitch.

        Peritoneal/intra-abdominal placement: removal is recommended when the peritoneal output is less than 50 mL per day. If there was significant preoperative ascites, discontinuation of the drain is when the fluid turns mainly serous.

•   Penrose drain and T-tubes: indicated for drainage of pelvic or subcutaneous infections. It is a passive drain.

•   Nasogastric tube: indicated for postoperative ileus or for bowel obstruction. It is placed to low intermittent suction or Gomco suction.

239CENTRAL VENOUS CATHETERS

Used to administer systemic cytotoxic agents, blood products, antibiotics, or in patients with poor peripheral access.

•   The Mediport is a subcutaneous port and catheter used for central venous access. It is accessed using a Huber needle. It needs a monthly flush with heparin. A CXR is needed after placement unless it is placed under fluoroscopic guidance.

•   A peripherally inserted central catheter, or PICC line, is a central venous line placed through a peripheral vein. Indications are for systemic cytotoxic agents, antibiotic therapy TPN, or in patients with poor peripheral access. A daily flush is needed but it can be left in place for 6 months. A CXR after placement is needed.

•   A Hickman catheter is a subclavian catheter used for central venous access. It has no subcutaneous pocket reservoir, so the rate of infection is higher. Indications are similar to the PICC line. It necessitates a daily flush. A CXR after placement is needed.

•   A Groshong catheter has similar indications for central venous access. It is a semipermanent central venous catheter. It needs a weekly flush. A CXR after placement is needed.

PERITONEAL CATHETERS

•   The Tenckhoff catheter is a type of intraperitoneal port-a-cath. It can be irrigated with 500 units of heparin in 15 mL normal saline flush QID × 3 days after placement. It needs a weekly maintenance flush.

•   The Bardport or Mediport 8–9.6F nonfenestrated port can also be used for intraperitoneal placement. It does not need a flush.

CATHETER TROUBLESHOOTING

•   If a blood clot obstructs the use of any vascular catheter, attempts at salvage with a thrombolytic agent are indicated. Patency can be checked by injection of Hypaque contrast or visualization under fluoroscopy. An example of a thrombolytic protocol is a urokinase flush with 5,000 units/mL solution. A 1-mL injection into the port is performed followed by a 3 mL normal saline flush. This is allowed to remain for 1 hour, then fluid withdrawal is attempted.

•   Fibrin sheath: this occurs and is diagnosed when there is difficulty withdrawing blood but the flush is smooth or has only moderate resistance. Treatment is placement of a new port if difficulty continues.

INSTRUMENTS

•   Robotics platforms: there are a few companies with robotic platforms. The benefits of robotics are: 3D laparoscopy, 7° of wrist movement compared to the 3° that conventional laparoscopy is capable of, minimization of tremor, and accentuated nodal dissection techniques. Although the cost of the program is high, the length of patient stay, amortization, and subjectively improved dissection techniques contribute to high-yield outcomes in oncologic surgery practices.

•   3D laparoscopy is now available to enhance depth of vision and facilitate dissection.

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