Surgical Drain Placement Research Articles

To drain or not to drain following a Sistrunk procedure: A dual institutional experience

IntroductionA Sistrunk procedure is the standard operative management of patients with thyroglossal duct cysts. Drain placement is commonly employed with the goal of reducing postoperative complications. This study investigates the association between drain use and relevant postoperative complications following pediatric Sistrunk procedures. MethodsRetrospective cohort study evaluating 295 pediatric patients treated between 2007 and 2016 at two tertiary care children's hospitals. ResultsThe mean age of the study population was 5.6 years (SD 4.0). A drain was utilized in 234 cases (79.3%). The mean procedural duration was 108 min (SD 48), and significantly longer in patients receiving a drain. Early postoperative complications included seroma (5.8%), secondary infection (3.4%), wound breakdown (2.0%) and hematoma (0.3%). The risk of such complications did not significantly differ between patients without drain placement (9.8%) versus those who underwent surgical drain placement (12.0%) after accounting for age and history of preoperative infection (adjusted RR = 0.86; 95% CI: 0.37, 1.98; p = 0.72). In the subgroup analysis, findings were consistent across institutions, age category, history of infection, and primary versus secondary procedure. ConclusionThis dual institutional study found drain placement during a Sistrunk procedure may not reduce rates of common postoperative complications, even in longer duration cases in which a drain is more frequently placed. This data suggests a Sistrunk procedure may be safely performed without drain placement in select cases.

Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma.

Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor. A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS). Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006). Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.

Impact of Drain Placement and Duration on Outcomes After Pancreaticoduodenectomy: A National Surgical Quality Improvement Program Analysis

BackgroundThe decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model. MethodsThe American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities. ResultsOf 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74). ConclusionsRoutine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

Surgical drains do not alter the spectrum of complications in distal pancreatectomy. An analysis of the NSQIP pancreatectomy database

Background: Distal pancreatectomy remains the procedure of choice for masses within the body and tail of the pancreas however post-operative pancreatic fistulas (POPF) continue to be the major source of morbidity. While we reasoned that drains may not reduce POPF, some evidence suggests they may reduce the frequency of related severe complications. We sought to evaluate the role of surgical drains in mitigating the frequency of severe complications related to POPF in distal pancreatectomy. Methods: We performed a retrospective cohort study of the procedure targeted, Pancreatectomy NSQIP database from 2014–2016. We included all patients who underwent non-emergent, distal pancreatectomy for any reason. We excluded patients with sepsis, or clinical instability. The primary endpoint was a modified clinically relevant POPF (mCR-POPF). This included any POPF that resulted in the need for percutaneous drainage, or was associated with sepsis, organ failure, reoperation, or death. We also looked at multiple secondary endpoints including percutaneous drainage, sepsis, septic shock, acute renal failure, re-operation, cardiac arrest, organ space infection and mortality. Multivariable logistic regression models were built for the primary and each secondary endpoint. Results: Based on our criteria, we identified 5,055 distal pancreatectomies eligible for analysis. Of these, 4679 had no mCR-POPF, while 376 did. In addition, drains were left in 4334 patients (85.7%). On multivariable logistic regression, surgical drain placement was not associated with mCR-POPF (OR 0.86, 95% CI 0.637–1.161, P = 0.325). Additionally, for each of the secondary endpoints evaluated, there was no evidence that surgical drain placement was associated with either an increase or a decrease in any of the outcomes (Percutaneous drainage OR 1.151, 95% CI 0.875–1.514, p 0.3143, Septic Shock OR 1.240, 95% CI 0.888–1.941, p = 0172, mortality OR 1.503, 95% CI 0.456 – 4.955, p = 0.503). Conclusion: Based on this analysis of the NSQIP procedure targeted pancreatectomy database, we did not find any evidence that surgical drains alter the frequency of mCR-POPF, or with related moderate to severe complications. As a result, the practice of standard drainage in the setting of distal pancreatectomy should be critically evaluated.Table 2Final adjusted odds ratios for the effect of surgical drain placement on each outcome based on multivariable logistic regression models.OutcomesOR95% CIp-valueRisk factors controlled formCR-POPF0.860.631.160.33Age, CHF hx, OP time, BMI, reconstruction, ASAPercutaneous drain1.150.881.510.31COPD hx, CHF hx, Chemo, OP time, BMI, ASA, reconstructionSepsis (including septic shock)1.310.891.940.17Sex, COPD hx, OP time, ASASeptic shock1.240.562.750.60Age, dialysis, OP time, ASARenal failure (very few events, 0.4%)3.240.4324.260.25ASATransfusion1.580.902.7580.11Dialysis, steroid, OP time, BMI, ASAReturn to OR0.980.641.5140.94COPD hx, OP time, ASA30-day mortality1.500.464.9550.50Age, steroid, OP timeCardiac arrest1.840.437.8200.41Age, OP timeOrgan space infection1.020.771.3420.89Sex, smoking, dialysis, steroid, OP time, BMI, ASA, reconstruct>=30 day admission0.640.281.4740.29COPD hx, OP time, ASA30-day mortality1.570.475.1980.46OP time, logit of predicted mortality Open table in a new tab Odds ratios for the effect of surgical drains on each outcome when adjusted for the indicated confounders. mCR-POPF (modified clinically relevant POPF), CHF (Congestive heart failure), OP time (operative time), BMI (Body Mass Index), COPD (Chronic Obstructive Pulmonary Disease), ASA (American Society of Anesthesiologist Class).

Longer Operative Time and Intraoperative Blood Transfusion are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

A comparative study of surgical drain placement and the use of kinesiologic tape to reduce postoperative morbidity after third molar surgery

Our aim was to compare the effects of the surgical drain and kinesiotape applications on postoperative morbidity after mandibular third molar surgery in a split-mouth study design. A single-centre, split-mouth study was performed in 23 patients who needed surgical removal of bilateral mandibular third molars. Each patient was treated with a drain tube on one side of the mandible and Kinesio tape (KT) on the contralateral side. Swelling was significantly greater in the KT group than in the drain group throughout the study period. The groups did not differ significantly in the amount of trismus at any time point. The Visual Analogue Scale (VAS)-measured pain intensity was significantly lower in the drainage group. Patients with KT had greater postoperative discomfort than those with a drain tube. All patients were generally satisfied with their treatments. Although both treatments were useful, a surgical drain was significantly more effective at reducing swelling and pain intensity than Kinesio tape. The effects of both on trismus were similar.

Risk Factors for Gastrointestinal Leak after Bariatric Surgery: MBASQIP Analysis

Gastrointestinal leak remains one of the most dreaded complications in bariatric surgery. We aimed to evaluate risk factors and the impact of common perioperative interventions on the development of leak in patients who underwent laparoscopic bariatric surgery. Using the 2015 database of accredited centers, data were analyzed for patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (LRYGB). Emergent, revisional, and converted cases were excluded. Multivariate logistic regression was used to analyze risk factors for leak, including provocative testing of anastomosis, surgical drain placement, and use of postoperative swallow study. Data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (n= 92,495 [69.3%]) and LRYGB (n= 40,983 [30.7%]) were analyzed. Overall leak rate was 0.7% (938 of 133,478). Factors associated with increased risk for leak were oxygen dependency (adjusted odds ratio [AOR] 1.97), hypoalbuminemia (AOR 1.66), sleep apnea (AOR 1.52), hypertension (AOR 1.36), and diabetes (AOR 1.18). Compared with LRYGB, laparoscopic sleeve gastrectomy was associated with a lower risk of leak (AOR 0.52; 95% CI 0.44 to 0.61; p < 0.01). Intraoperative provocative test was performed in 81.9% of cases and the leak rate was higher in patients with vs without a provocative test (0.8% vs 0.4%, respectively; p < 0.01). A surgical drain was placed in 24.5% of cases and the leak rate was higher in patients with vs without a surgical drain placed (1.6% vs 0.4%, respectively; p < 0.01). A swallow study was performed in 41% of cases and the leak rate was similar between patients with vs without swallow study (0.7% vs 0.7%; p= 0.50). The overall rate of gastrointestinal leak in bariatric surgery is low. Certain preoperative factors, procedural type (LRYGB), and interventions (intraoperative provocative test and surgical drain placement) were associated with a higher risk for leaks.

Minimally invasive surgical technique for tethered surgical drains.

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 cannot 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.

Antibiotic Prophylaxis in Radical Prostatectomy: Comparison of 2-Day and More than 2-Day Prophylaxis.

The efficacy of antibiotic prophylaxis in radical prostatectomy (RP) remains to be established. We retrospectively compared the occurrence of perioperative infections after RP between the 2 different antibiotic protocols. This study involved 428 cases of laparoscopic radical prostatectomy (LRP). After excluding patients who had no perioperative urine culture data, 313 consecutive patients who underwent LRP for prostate carcinoma were classified into 2 groups according to the duration of antimicrobial prophylaxis. To group 1 (153 patients), a second-generation cephalosporin was administered for less than 2 days, whilst the remaining 160 patients in group 2 were administered the drug for more than 2 days. The overall incidence of postoperative bacteriuria was 50.8%, being significantly higher in group 1 (56.9%) than in group 2 (45%). The incidence of surgical site infection (SSI) was significantly higher in group 1 (5.2%) than in group 2 (0.6%). Multivariate analysis revealed that old age, duration of antibiotics for more than 2 days, and duration of Foley catheter placement were independently associated with postoperative infectious complications (all, P < 0.05). Multivariate analysis revealed that duration of antibiotics for more than 2 days, duration of Foley catheter placement, and duration of surgical drain placement were independently associated with postoperative SSI (all, P < 0.05). The incidence of postoperative bacteriuria and SSI were higher in patients who received antibiotics for a short duration. Based on our results, we demonstrated that the outcome of postoperative infectious complications is dependent on old age, short antibiotic administration duration, and prolonged Foley catheterization. Prolonged drain placement is associated with SSI, whilst a longer duration of antibiotics use and prolonged Foley catheterization are associated with a decrease in the incidence of SSI.

What is a better predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD): postoperative day one drain amylase (POD1DA) or the fistula risk score (FRS)?

BackgroundBoth fistula risk score (FRS) and drain amylase in postoperative day 1 (POD1DA) have been promoted as tools to guide placement and removal of surgical drains following pancreaticoduodenectomy (PD). However, their individual utility has not been compared. MethodsA consecutive cohort of PD patients from 2013 to 2015 were identified from a prospectively collected institutional database. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated for FRS (negligible/low vs. moderate/high) and POD1DA of 600 U/L and 5000 U/L as predictors of clinically relevant postoperative pancreatic fistula (CR-POPF). ResultsThe incidence of CR-POPF was 27% in 216 patients. Sensitivity and specificity of FRS, POD1DA >600 U/L, and POD1DA >5000 U/L for predicting CR-POPF were 83% and 55%, 94% and 60%, 33% and 90%. The ROC area under the curve (AUC) for POD1DA >600 U/L (0.764) and FRS (0.749) were not significantly different (p = 0.713). However, POD1DA >5000 U/L (0.615) was significantly worse at predicting CR-POPF (p = 0.015). When FRS and POD1DA >600 U/L were combined; there was no improvement (p = 0.624). DiscussionFRS and POD1DA are equally accurate in predicting CR-POPF. Patients with negligible/low FRS or POD1DA <600 U/L should be considered for drain removal.

Postoperative Prophylactic Antibiotic Use following Ventral Hernia Repair with Placement of Surgical Drains Reduces the Postoperative Surgical-Site Infection Rate.

To help prevent complications after incisional ventral hernia repair, traditional teaching has recommended using closed suction drains. However, some studies suggest that there is an increased infection risk with use of surgical drains, and it is uncertain whether use of extended postoperative prophylactic antibiotics while drains remain in place helps prevent surgical-site infections. Evidence guiding surgeons' clinical practice regarding antibiotic use following hernia repair is lacking. The authors sought to determine whether the use of extended postoperative antibiotic prophylaxis beyond standard Surgical Care Improvement Project guidelines with closed-suction surgical drain placement in incisional ventral hernia repair reduces the incidence of postoperative surgical-site infections. A retrospective review of 234 patients who underwent an incisional ventral hernia repair from 2003 to 2013 at a single institution was performed. Demographic, preoperative, operative, and postoperative data were collected and analyzed. Extended postoperative prophylactic antibiotics significantly reduce the incidence of postoperative surgical-site infections (OR, 0.31; p < 0.01). The odds ratio, when stratified by Ventral Hernia Working Group Scale, was 0.63, 0.25, 0.30, and 0.13 (p < 0.001 by the Mantel-Haenszel combined test) for grades 1, 2, 3, and 4, respectively, but was not statistically significant for differences between hernia grades. However, as the hernia grade increased, the odds ratio tended to decrease, suggesting that extended prophylactic antibiotics may be more effective at decreasing the incidence of surgical-site infections at higher grades. Extended antibiotic prophylaxis reduces surgical site infection risk following complex ventral hernia repairs, and should be considered in all cases. Therapeutic, III.

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

Postoperative Prophylactic Antibiotic Use Following Ventral Hernia Repair with Placement of Surgical Drains Reduces Postoperative Surgical Site Infection Rate

Postoperative Prophylactic Antibiotic Use Following Ventral Hernia Repair with Placement of Surgical Drains Reduces Postoperative Surgical Site Infection Rate

Clinical profile and methodology in the management of inflammatory benign breast lesions

There is a high incidence of mammary infections among females who attend the emergency department or surgery outpatient department. Acute bacterial mastitis either resolves under antibiotic therapy or evolves towards a pyogenic abscess. Traditional treatment of breast abscesses is by surgical incision, digital disruption of septa, evacuation of contents with occasional placement of surgical drains, and administration of systemic antibiotics. This strategy often requires general anaesthesia, may leave unpleasant scars, is more expensive than aspiration, requires regular postoperative dressing changes, and interferes with lactation. Overall, about 10–38% of abscesses recur and require additional surgical drainage. Needle aspiration of the pus in breast abscesses has been reported both with and without ultrasound guidance. It causes less scarring, does not affect breast-feeding, nor does it require general anaesthesia or hospitalization. It is in fact a less expensive procedure than surgery. This study was applied to all patients with mammary infections. Ultrasound-guided drainage was done for abscesses of limited size. If the abscesses were bigger or when image-guided aspiration was not effective, they were considered for operative intervention.

Modification of two-incision trans-axillary robotic thyroidectomy

The objective of this study is to describe the modification of port placement for the four-arm technique of robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. The study methodology involved description of port placement modification to avoid chest incision and report of two cases with appropriate literature review is presented. Trans-axillary robotic thyroidectomy (TART) is often performed with a second chest incision, but the move toward single incision operation and placement of four arms via a single incision require expertise. We describe two patients who underwent TART using a trans-axillary incision and a separate 1 cm incision in the anterior axilla 2.5-cm below the trans-axillary incision for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port was used for surgical drain placement Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and not occupying the working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.

Is drain placement necessary in pediatric patients who undergo the Sistrunk procedure?

BackgroundThyroglossal duct cysts are usually managed with the Sistrunk procedure, which involves excision of the cervical cyst with the central portion of the hyoid bone, along with its tract. Surgical drains are commonly placed with this procedure, which necessitates postoperative hospital admission. ObjectiveThe aim of this study is to determine if surgical drain placement is necessary in pediatric patients who underwent the Sistrunk procedure. MethodsThe current study describes the outcomes of 30 consecutive children who underwent the Sistrunk procedure without drain placement. Complication rates are compared to an age-matched control group who had drains placed. ResultsNo major complications, including hematomas were observed in the study group; outpatient surgery was safely observed in 20 patients. No significant difference in complication rates was observed between the study and control groups. ConclusionsRoutine drain placement in children who are undergoing the Sistrunk procedure may not be necessary. Subsequently, postoperative admission may be avoided.

Factors Predictive of Increased Surgical Drain Output After Anterior Cervical Discectomy and Fusion

Retrospective cohort study. To identify factors that are independently associated with increased surgical drain output in patients who have undergone ACDF. Surgical drains are typically placed after ACDF to reduce the risk of complications associated with neck hematoma. The orthopedic literature has repeatedly challenged the use of surgical drains after many procedures, and there are currently no guidelines for determining which patients are most likely to benefit from drain placement after ACDF. Consecutive patients who underwent elective ACDF with surgical drain placement at a single academic institution between January 2011 and February 2013 were identified using billing records. Patient information was abstracted from the medical record. Patients were categorized on the basis of normal or increased total drain output, with increased drain output defined as total drain output 50th percentile (30 mL) or more. A multivariate logistic regression was used to determine which factors were independently associated with increased drain output. A total of 151 patients with ACDF met inclusion criteria. Total drain output was in the range from 0 mL to 265 mL. The average drain output for this cohort was 42.3 ± 45.5 mL (mean ± standard deviation). Among all patients in the study, 80 patients had increased drain output (drain output ≥50th percentile or 30 mL).Multivariate analysis identified 3 independent predictors of increased drain output: age 50 years or more (odds ratio [OR] = 3.9), number of levels (2 levels, OR = 2.7; 3-4 levels, OR = 17.0), and history of smoking (OR = 2.8). One patient developed a postoperative neck hematoma while a drain was in place. Patients with the factors associated with increased drain output identified in the earlier text may benefit most from surgical drain placement after ACDF. Nonetheless, neck hematoma is still possible even with drain use. 3.

Trans‐axillary Robotic Thyroidectomy: Avoiding the Chest Port

Objectives: Describe modification of port placement for the four-arm technique for robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. Methods: Description of port placement modification to avoid chest incision as well as report of two cases and appropriate literature review. Results: Placement of four arms via a trans-axillary incision requires expertise. Transitioning from a chest port for placement of the fourth arm to a single-incision surgery, avoiding a visible chest incision, can be challenging. We describe this technique and two cases of trans-axillary robotic hemithyroidectomy (TART) using a trans-axillary incision and a separate 1 cm incision in the anterior axilla, 2.5 centimeters below the trans-axillary incision, for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port is used for surgical drain placement. Conclusions: Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and without occupying the restricted working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.

The Effect of Cesarean Delivery Skin Incision Approach in Morbidly Obese Women on the Rate of Classical Hysterotomy

Objective. To assess the risk of classical hysterotomy and surgical morbidity among women with a body mass index (BMI) greater than 40 kg/m2 who underwent a supraumbilical incision at the time of cesarean delivery. Methods. We conducted a retrospective cohort study in women having a BMI greater than 40 kg/m2 who underwent a cesarean delivery of a live, singleton pregnancy from 2007 to 2011 at a single tertiary care institution. Intraoperative and postoperative outcomes were compared between patients undergoing supraumbilical vertical (cohort, n = 45) or Pfannenstiel (controls, n = 90) skin incisions. Results. Women undergoing supraumbilical incisions had a higher risk of classical hysterotomy (OR, 24.6; 95% CI, 9.0–66.8), surgical drain placement (OR, 6.5; 95% CI, 2.6–16.2), estimated blood loss greater than 1 liter (OR, 3.4; 95% CI, 1.4–8.4), and longer operative time (97 ± 38 minutes versus 68 ± 30 minutes; P < .001) when compared to subjects with Pfannenstiel incisions (controls). There was no difference in the risk of wound complication between women undergoing supraumbilical or Pfannenstiel incisions (OR, 2.7; 95% CI, 0.9–8.0). Conclusion. In women with a BMI above 40 kg/m2, supraumbilical incision at the time of cesarean delivery is associated with a greater risk of classical hysterotomy and operative morbidity.

Spontaneous resolution of an inferior epigastric artery pseudoaneurysm secondary to surgical drain placement

We report the case of a 73-year-old woman who was found to have an inferior epigastric artery pseudoaneurysm caused by surgical drain placement during a laparotomy for an appendix abscess. She presented with pain around the drain site two months following surgery and intravenous contrast computed tomography (CT) revealed a right inferior epigastric artery pseudoaneurysm. A decision was made to manage this expectantly as she remained stable with no other complications. Following a period of nine months of observation, repeat intravenous contrast CT showed evidence of spontaneous regression and thrombosis of the pseudoaneurysm. She remains well and her symptoms have now resolved.