The prophylactic use of operative site drainage has been controversial in spite of advances in surgical techniques and perioperative management over the last two to three decades [1-5]. Despite limited availability and data suggesting limited benefits prophylactic operative site drainage after elective hepatectomy is routinely used. Clinically, the reasons for a prophylactic drain are early detection of complications (bile leakage or postoperative bleeding) and reduced need for radiological interventions (preventing complicated fluid collection) [6]. However, the use of a prophylactic drain is associated with disadvantages, such as drain infection by normal skin flora leading to retrograde infection, vascular injury, intestinal ulcer, and longer hospitalization period. The use of a prophylactic drain after hepatectomy or other abdominal surgeries has been debated based on the current evidence-based research, and numerous studies have found no advantage of prophylactic drain insertion [7,8]. However, in these studies, the decision to insert a drain after hepatectomy was based on each institution’s protocol, the degree of resection, and the surgical approach used, all of which resulted in selection bias. Therefore, we attempted to determine the differences in postoperative results between non-use and use of drain when drain insertion was determined by the intraoperative situation during the left lateral sectionectomy of the liver, which is relatively safe.

A total of 31 patients underwent left lateral sectionectomy at the Pusan National University Hospital between January 2017 and June 2020 (42-month period). Synchronous cases with combined resection of other parts of the liver or organs, such as the colon, were excluded. The Institutional Review Board of the Pusan National University Hospital Clinical Trial Center approved the study (approval no. 2111-009-108). The patients’ data were retrospectively reviewed. The patients were divided into the drainage (n = 16) and non-drainage (n = 15) groups. Prior to surgery, informed written consents were obtained from the patients that they would not have drain insertion and that radiologic intervention might be performed afterward if required. However, if the degree of cirrhosis was severe or there was a root of bleeding during the surgery, drain insertion was performed after explaining the requirement to the patient’s guardian. The following clinical characteristics were retrospectively reviewed from the patients’ records: age, sex, comorbidities, American Society of Anesthesiologists scores, previous surgery, pathological findings, and surgical method.

A total of 31 patients underwent isolated left lateral sectionectomy of the liver during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma (HCC), three with intrahepatic cholangiocarcinoma, three with liver metastasis, and three with benign liver disease. The patients’ mean age was 61.94 years (range, 42–84 years). Patients were predominantly male (71.0%) and the male-to-female ratio was 22 : 9. Twenty-two patients had comorbidities, such as hypertension, diabetes mellitus, cardiovascular disease, and epilepsy (Table 1). Twenty-two patients were found to have a positive serology for hepatitis B or C, and twelve patients had cirrhotic liver which was confirmed by pathological examinations. Six patients (19.4%) had a history of abdominal surgery. Of these, three patients previously underwent laparoscopic low anterior resection, two patients underwent liver segmentectomy, and one patient underwent right posterior sectionectomy. HCC was the most common carcinoma (n = 22, 71.0%). Laparoscopic surgery was performed in 10 patients (32.3%). The patient’s preoperative laboratory findings such as total bilirubin, albumin, indocyanine green, and platelet counts showed no significant differences among the groups (Table 2).

There were no differences in various clinicopathological variables between the drainage and non-drainage groups. Although the frequency of comorbidities was higher in the non-drainage group than in the drainage group, the differences were not statistically significant (p = 0.06). There were no differences between the two groups in terms of the operation time, the volume of intraoperative bleeding, and background liver status, which are important factors in determining drain insertion during surgery. The postoperative hospital stay was significantly shorter in the non-drainage group compared to the drainage group (5.87 ± 2.20 days vs. 8.44 ± 2.48 days, p = 0.01; Table 3). No complications, including bile leak, bleeding, and abnormal fluid collection, were observed in either of the groups, and there were no readmissions within 30 days. No morbidity or 90-day mortality occurred.

The left lateral section of the liver occupies a relatively small volume, is clearly separated from the surrounding tissue, and is composed of a simple intrahepatic duct, which makes the surgical approach easy and safe. Consequently, the incidence of postoperative complications is lower than in other liver procedures. A recent study suggested that prophylactic drainage may not be necessary and it is not associated with a higher risk of complications in safely performing hepatic resection [3,8]. Our results were consistent with the findings of this study. Despite this, surgeons habitually use the drain to prevent possible complications such as bile leakage and postoperative bleeding surveillance, and to reduce the need for radiological interventions to prevent complicated fluid collection [6]. However, it is not easy to apply it without each surgeon’s experience and belief. This study aimed to determine whether drainage of the operative site can be avoided in future major hepatectomies based on clinical results after left lateral sectionectomy. Although left lateral sectionectomy is relatively safe but is not without complications. In the case of left lateral sectionectomies performed on donors with a normal background liver, the frequency of biliary complications, including bile leak, is reported to be 1.4% to 4.3% [9-11]. In addition, van der Poel et al. [12] found that the frequency of severe complications (abdominal fluid collection requiring drainage, bleeding requiring reoperation, respiratory insufficiency, and sepsis) was 13%, and the mortality rate within 90 days was 1%. In our study, there were no severe complications. However, abnormal fluid collection can occur despite drain insertion and can be controlled using ultrasonography-guided percutaneous drainage. In left lateral sectionectomy it is relatively easy to perform radiological interventions than in other liver procedures. This study showed that drain placement increased the hospitalization period in patients undergoing left lateral sectionectomy; however, the reason is unclear. In this study, CT was performed on POD 5 and if there were no abnormalities present, the drain was removed, and discharge within 7 days was aimed. This took into account the characteristics of the medical environment, in which many were reluctant to be discharged early. In the non-drainage group, if clinical symptoms worsened after the postoperative period or improvement in blood chemistry was delayed, CT was performed early. In these cases, if there was no abnormal fluid collection, the patient was discharged earlier than planned. There were no cases of early readmission. In this study, if the liver condition was poor, surgery was difficult, or there was significant bleeding, drain insertion was performed. However, our results showed no differences between the two groups.

This study had several limitations. First, the surgeon’s subjective judgment was taken into consideration in deciding whether to perform drain insertion during surgery. Second, we conducted a retrospective analysis at a single center. Finally, our sample size was small and the analyses lacked a multivariable model to assess the independent associations between the drainage and non-drainage groups. A consensus on the need, safety, and efficacy of surgical drainage has not been reached because of the lack of large-scale multicenter studies and limited available data; therefore, multicenter studies including surgeons with various experiences are needed to overcome early shortcomings and derive better results. Despite these limitations, it is suggested that drain insertion may not be necessary, depending on the surgeon’s preference. Based on our results, routine surgical drainage after elective hepatectomy may not be helpful.

In conclusion, prophylactic drainage insertion is unnecessary in the prevention of abnormal fluid collection after elective left lateral sectionectomy and sectionectomy without surgical drainage is not associated with a longer hospital stay.