Selective Drain Placement in Complicated Laparoscopic Cholecystectomy: Indications, Intraoperative Determinants, and Outcomes.

BACKGROUND

The utility of intraoperative drain placement after complicated laparoscopic cholecystectomy (cLC) remains poorly defined. Present evidence strongly discourages the routine drainage after uncomplicated procedures and its role in high-risk intraoperative scenarios such as intraoperative contamination, bile leak, and others, which requires further characterization.

OBJECTIVES

This study aims to assess the utility of drains in detecting postoperative complications such as bile leaks and hemorrhage, and to evaluate their role and necessity in cLC.

METHODS

A prospective descriptive longitudinal study was conducted over 18 months (January 2024-June 2025) at a tertiary care teaching institute. Seventy-six patients who underwent cLC with intraoperative drain placement meeting the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria were enrolled. Demographic data, intraoperative findings (Parkland Grading Scale (PGS), critical view of safety (CVS) achievement, operative duration), indication for drain placement, daily drain output, visual analog scale (VAS) pain scores, and postoperative complications were recorded and analyzed using IBM SPSS Statistics for Windows, Version 21 (Released 2012; IBM Corp., Armonk, New York, United States).​​​​​​

Results

Mean age was 49.86 ± 13.27 years, with 44 (57.9%) female participants and a median hospital duration of four days. The most common indications for drain placement were hemorrhage risk, infection or contamination, and anatomical difficulty observed in 28 (36.8%), 21 (27.6%), and 13 (17.1%) patients, respectively. Parkland Grade III was the most prevalent intraoperative finding in 37 (48.7%) patients, with a CVS achieved in 67 (88.2%) of them. The CVS had a highly significant association with reason for drain placement (p < 0.001). Drain output was predominantly serosanguineous; bilious drainage occurred exclusively in the bile leak risk group, validating selective drain use. Precautionary drains were removed as per the standard recommendations (3-4 days), as compared to the risk-driven drains (hemorrhage, bile leak, infection) required retention for a duration of 5-7 days. VAS scores declined progressively from 6 to 1 on day 1 and day 6, respectively. One postoperative bile leak was identified and successfully managed by reexploration and transfixation of the blowout cystic duct stump with no other major postoperative complications.

CONCLUSION

Selective drain placement in cLC is clinically justified and effective. Drain output patterns correlated with the intraoperative indication, supporting an indication-guided approach to duration of drain retention. A tailored drain use aligned with the SAGES guidelines is recommended to improve patient safety by preventing morbidity.