surgical drain placement has its earliest roots dated back to hippocrates ( 460 - 377 bc).123 in orthopedic surgery , as well as other surgical specialties , surgical drains are mainly used to prevent fluid collections and to provide outflow for infections.1 the use of surgical drains has been controversial .
suggested that the use of surgical drains in arthroplasty increases blood loss , transfusion requirements , and overall costs.4 however , when the decision is made to use surgical drains , attention to detail and technique is of the utmost importance .
specifically , during surgical wound closure , a surgical drain may be inadvertently pierced by a suture needle causing tethering of the drain to the surgical wound .
attempts at the removal of this tethered drain at bedside may be unsuccessful or result in breakage causing a drain fragment to be left in the wound .
retention of such drain fragments may not cause direct harm but often causes distress , embarrassment , and may result in litigation.56 there have been several articles describing the preventive and removal techniques of such tethered drains.578910 this article describes a minimally - invasive surgical technique for tethered drain removal when nonsurgical measures fail .
this technique evolved when a tethered drain was discovered on 1 postoperative day following revision total hip arthroplasty .
standard bedside removal techniques failed forcing a decision either to pull hard enough to break the drain and leave a retained drain fragment or return to the operating room for formal wound exploration . before exposing the patient to the morbidity associated with formal wound exploration ,
this article demonstrates the technique involving a standard 400 cc three spring davol closed wound suction evacuator with a pvc drain ( bard medical , covington , ga , usa ) [ figure 1a ] and a 7.4 mm inner diameter 13.5  working length closed tendon stripper ( smith and nephew , andover , ma , usa ) [ figure 1b ] .
photographs showing ( a ) 400cc three spring davol closed wound suction evacuator with a pvc drain and trocar ( bard medical , covington , ga , usa ) ( b ) 7.4 mm inner diameter 13.5  working length closed tendon stripper ( smith and nephew , andover , ma , usa ) the patient is placed in the supine position on a radiolucent table and anesthesia is provided via conscious sedation .
fluoroscopy is utilized , and images of the entire drain are confirmed before the start of the case .
once tethering is confirmed the surgical drain is removed from its suction canister and cut so that enough tail can be prepped and draped into the surgical field [ figure 2a ] .
the skin and soft tissues along the course of the drain are anesthetized with 20 ml of 1% lidocaine without epinephrine .
a surgical blade is used to incise the skin parallel to the path of the surgical drain making sure it is large enough to allow passage of the tendon stripper .
the tail of the surgical drain is pulled to expose enough sterile drain from underneath the skin and then grasped with a clamp at the level of the skin to prevent retraction [ figure 2b ] .
the tail distal to the marked line is then cut and removed [ figure 3a ] .
the surgical drain is threaded through the opening of the tendon stripper and grasped with another clamp while the clamp at the level of the skin is removed .
the tendon stripper is advanced underneath the skin and guided along the path of the surgical drain .
the tendon stripper is provided with a clockwise and counter clockwise alternating rotation while gentle traction is applied to the surgical drain paying attention to any resistance , much like would be done for harvesting hamstring tendons during an anterior cruciate ligament reconstruction [ figure 3b and c ] .
advancement of the tendon stripper continues until the level of tether is reached , which can be identified by a distinct resistance and lack of easy advancement . at the level of tether ,
controlled pressure is applied to the tendon stripper along with gentle rotation and pushed passed the restrictive barrier , cutting the suture , and freeing the drain [ figure 4a and b ] .
fluoroscopy is used to confirm complete removal of the surgical drain , and that drain fragments were not retained [ figure 5a and b ] .
silk suture was used to tether the drain to soft tissue near the hip joint ( b ) drain is pulled to expose
 sterile drain  from underneath the skin photographs showing ( a ) cutting of the tubing distal to the marked line leaving  sterile tubing  only ( b ) drain is passed through the opening of the tendon stripper .
the drain is grasped to prevent retraction of the drain back underneath the skin ( c ) advancing the tendon stripper along the path of the surgical drain photographs showing ( a ) tendon stripper advanced until the site of the tether is reached . in this cadaver simulation ,
the drain is sutured to soft tissue utilizing silk suture with multiple knots ( b ) the tendon stripper is pushed passed the restrictive barrier in a controlled fashion until the drain is freed .
the suture is cut and the drain is intact fluoroscopic image during operating room evaluation showing the tethered surgical drain while gentle traction is applied indicating ( a ) the level of tether ( b ) surgical drain successfully removed utilizing the tendon stripper technique with no retention of drain fragments after the success of this technique in the operating room , it was taken to the cadaver laboratory for simulation .
the same type of drain that was used above was sutured to tissue via silk suture with multiple knots in a cadaver hip specimen .
successful release of the tethered drain utilizing this technique was confirmed in the cadaver laboratory for simulation .
the true incidence of tethered drains is not known since it is an uncommon event . however , when it does occur , it can cause embarrassment to the surgical team and increase the risk to the patient as well as increase cost if a return trip to the operating room for formal wound exploration is needed .
several articles have previously discussed the preventive and removal techniques of tethered drains.578910 lazarides et al.7 described the use of a steinmann pin to extract a drain by inserting the sharp end of the pin into the lumen of the surgical drain to cut the suture .
namyslowski et al.8 described the use of an angioplasty balloon to retrieve drain fragments , whereas rue and johnson10 described a technique to remove a snared silicone drain by twisting the drains five to seven turns while gentle in - line traction was applied .
this article describes a new technique to remove a tethered drain in a minimally - invasive fashion .
the technique of using a tendon stripper to engage a tethered surgical drain , to our knowledge , has not been previously described in the literature .
it demonstrates an unconventional application of a common instrument found in almost every hospital operating room .
this technique utilized conscious sedation in addition to local anesthesia in the operating room setting .
application of this technique however can theoretically be attempted at the bedside with adequate local anesthesia and aseptic technique .
previous studies have suggested that infiltration of local anesthetic into the skin wound and around the surgical drain tube or into the surgical drain tube itself provides a painless and comfortable experience to the patient during drain removal.111213 these studies however do not involve that of a tethered drain .
another area of concern when injecting local anesthetic into the drain itself is the theoretical risk of infection , especially in the setting on an arthroplasty . in this article
, we demonstrate the technique utilizing fluoroscopic guidance , which can help locating the site(s ) of tethering as well as provide confirmation of complete drain removal ; however , this is not necessary .
although this article describes its use in a hip arthroplasty case , this technique can be easily adapted to other areas of the body with a tethered drain and by varying the size of the tendon stripper .
however , one must be cautious of drain location and have knowledge of the surrounding anatomical structures .
specific contraindications to this procedure may include those drains that are placed in deeper planes near critical structures or near nerves and major blood vessels where introduction of a tendon stripper may cause injury .
for example , in hip cases , a common site of tether is at the fascia lata level where it is common practice to utilize a continuous running stitch .
if this type of stitch is cut , then this may compromise wound closure of the deep layers resulting in increased chances for wound complications and other sequela .
a continuous running stitch without barbs or additional interrupted stitches to reinforce closure may be another contraindication to this technique . in conclusion , we present a minimally - invasive surgical technique for tethered drain removal that can avoid the need for a formal wound exploration , which increases anesthesia and infection risk as well as cost .
 a feared complication of temporary surgical drain placement is from the technical error of accidentally suturing the surgical drain into the wound . 
 postoperative discovery of a tethered drain can frequently necessitate return to the operating room if it can not be successfully removed with nonoperative techniques . 
 formal wound exploration increases anesthesia and infection risk as well as cost and is best avoided if possible . 
 we present a minimally invasive surgical technique that can avoid the morbidity associated with a full surgical wound exploration to remove a tethered drain when other nonoperative techniques fail . 
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