Routine abdominal drainage versus no drainage after elective hepatectomy: A systematic review and meta-analysis

The value of routine abdominal drainage after hepatectomy remains controversial. Although drains have traditionally been used to detect bile leakage or postoperative bleeding and to evacuate intra-abdominal collections, their routine use after elective liver resection has increasingly been questioned.

A systematic review and metaanalysis of randomized controlled trials comparing routine abdominal drainage with no drainage after elective hepatectomy was performed. PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library were searched from inception to 1 April 2026 using predefined terms related to hepatectomy, drainage, and randomized trials. The outcomes of interest included overall postoperative morbidity, postoperative mortality, wound-related complications, bile leakage or biliary fistula, subphrenic or perihepatic fluid collection, and length of hospital stay. Risk of bias was assessed using the Cochrane RoB 2 tool.

Six randomized controlled trials involving 1,025 patients were included, with 513 patients allocated to routine drainage and 512 to no drainage. Routine drainage was associated with higher overall postoperative morbidity (RR 1.41, 95% CI 1.16-1.71; I² = 32.5%) and more wound-related complications (RR 2.75, 95% CI 1.56-4.86; I² = 36.1%). Postoperative mortality remained low and did not differ significantly between groups (RR 1.20, 95% CI 0.50-3.00; I² = 0%). Reported bile-leakage events were more frequent in the drainage group (RR 5.02, 95% CI 1.53-16.48; I² = 0%); however, this outcome is highly susceptible to ascertainment bias because the opportunity to detect bile leakage differs according to drain status. Subphrenic/perihepatic collection did not differ clearly between groups (RR 1.02, 95% CI 0.48-2.15; I² = 71.4%). Length of hospital stay showed a small pooled difference favoring drainage (MD -0.35 days, 95% CI -0.50 to -0.20), but between-study heterogeneity was substantial (I² = 82.3%) and the trial-level directions were inconsistent.

Current randomized evidence does not support routine abdominal drainage after elective hepatectomy, particularly in uncomplicated or standard-risk cases. A selective rather than routine strategy appears more appropriate, and the apparent bile-leakage signal and hospital-stay result should be interpreted in light of ascertainment bias, outcome-definition differences, and substantial between-study heterogeneity.