In January 2016, we instituted a goal of universal intraperitoneal drain placement at the time of laparotomy for removal of sacrocolpopexy mesh in an effort to decrease postoperative morbidity. This quality improvement study aims to determine the rate of implementation of this intervention and to test the null hypothesis that intraperitoneal drain placement has similar rates of postoperative fluid collection and readmission as historic controls without drains.

We performed a retrospective cohort study of 20 patients undergoing abdominal surgery for removal of sacrocolpopexy mesh between January 2008 through January 2018. All surgeries were performed by urogynecologists at a single tertiary care center. Chart review was performed to collect patient demographic and perioperative data including surgical indication, whether an intraperitoneal drain was placed, type of drain, whether a postoperative fluid collection was diagnosed and how this was managed, length of hospitalization, and readmission within 90 days. Fisher’s exact test was used to compare outcomes between patients with and without drain placement. A p-value <.05 was considered statistically significant.

The mean age (± standard deviation) was 57±10 years with a mean BMI of 27±6 kg/m2. Eighty percent of patients self-identified as White/Caucasian, 15% had diabetes, and 20% were smokers at the time of surgery.  The mean time from index sacrocolpopexy to mesh removal was 3.8±3.1 years and the common indications for mesh removal included vaginal mesh exposure, pain, vaginal bleeding or discharge, and dyspareunia. In 30% of patients (6/20), infection of the tissue surrounding the mesh was suspected preoperatively, and in 1 patient a preoperative presacral abscess was identified on imaging. In 4 additional patients, an infection was suspected intraoperatively. The median estimated blood loss (EBL) for the procedure was 188 mL (interquartile range 100, 338 mL). A total of 45% of patients (9/20) had intraperitoneal drain placement at the time of mesh removal. Most patients had a Jackson-Pratt (JP) drain placed (7/9), 2 had a Malecot drain, a 1 had both JP and Malecot drains placed. Implementation of the quality improvement plan was successful, with the rate of drain placement increasing from 28.6% to 83.3% (p=.050). Five patients (25%) had a new fluid collection diagnosed postoperatively. Those with a drain in place were significantly less likely to be diagnosed with a new postoperative fluid collection than those without drain placement (0 versus 45.5%, p=.04). There was also a trend toward increased risk of readmission without drain placement, but this was not statistically significant at our sample size (45.5 vs 11.1%, p=.16).

This quality improvement project indicates that we successfully increased the rate of intraperitoneal drain placement at the time of abdominal removal of sacrocolpopexy mesh after implementing this policy in 2016. Intraperitoneal drain placement was associated with a lower rate of postoperative fluid collection.

In our cohort of twenty patients undergoing abdominal mesh removal, intraperitoneal drain placement is associated with a lower rate of postoperative fluid collections. This low-risk intervention at the time of surgery appears to be worthwhile to reduce postoperative morbidity. Future prospective studies are needed to further characterize the effect.