The Removable Buried Retention Suture: A New Technique DEAN BARTON SMITH, M.D.
From The Department of Surgery, Through-and-through retention sutures are inherently inefficient Madison General Hospital, and prone to produce skin and subcutaneous damage. Most surMadison, Wisconsin geons are reluctant to permanently bury non-absorbable retention sutures. This new technique uses tube conduits to bring the retention sutures from deep fascial level to above the skin-surface, where they are available for removal. Thus, the sutures do non-absorbable material, there is a reluctance to permanot cross the skin and subcutaneous tissue, and they exert maxi- nently bury them under considerable tension because of mal efficiency at the deep fascial layers. This method has been permanent patient discomfort and potential problems if used in over 60 cases without deep-wound separation, and cominfection occurs. Therefore, the sutures are brought out plications have been minimal.
RETENTION SUTURES are used commonly in abdominal surgery to protect the main wound closure by exerting tension on the fascial and muscular layers several centimeters lateral to the main suture lines. They are indicated, especially, in the very obese, those with chronic pulmonary disease, malignancies, debility, and in those patients in whom postoperative abdominal distention can be anticipated because of the nature of the pathology. However, some surgeons use them almost routinely since their use can allow a somewhat simpler main wound closure, such as the use of continuous sutures. The technique of placing retention sutures varies from surgeon to surgeon. Commonly, they are placed through-and-through, traversing the peritoneal cavity from side to side (Fig. 1), and thus having the potential of trapping bowel between suture and peritoneum. Because retention sutures are made of quite heavy Submitted for publication March 21, 1975. Reprint requests: Dean Barton Smith, M.D., 20 S. Park Street, Madison, Wisconsin 53715.
through the subcutaneous panniculus and skin, and tied externally across the incision, where they are available for removal. Various methods have been devised in an attempt to protect the skin and subcutaneous tissue from damage, the most common being passing the sutures through rubber bolsters (Fig. 1). More recently various bridge devices have been used. These techniques attempt to dissipate the pressure consequent on adequate tension on the suture over a wide area, thereby minimizing damage. Unfortunately, the laws of force demand that the force applied to the skin be equal to that applied to the fascia, and the skin and subcutaneous tissue add little strength to the abdominal wall. Furthermore, by applying vectors, it is obvious that in all through-and-through techniques the direction of pull at the fascial level is 450 away from the desired horizontal plane (Fig. 1). It is clear that throughand-through retention sutures are inherently inefficient and have been a mixel blessing. If tied sufficiently tight to relieve the main wound closure of much of the abdominal-wall tension, skin and subcutaneous damage are likely to occur, especially in the obese patient. If not tied tightly, such sutures do not provide primary protec-
26
VOl. 182 NO. I
REMOVABLE BURIED RETENTION SUTURE
27
r7 ~E
-:'
=L
XS-
FIG. 1. Commonly used technique of placing retention sutures. Note potential trapping space between suture and peritoneum. Vector arrows illustrate net direction of force at the turning points of the suture in the posterior fascia and skin.
tion of the incision, and if there is partial separation of the incision, their bowstringing invites fistulization. A new technique has been developed which completely avoids these hazards by bringing the retention sutures from fascial level to above-skin level through retentionsuture-wound tubes, their length matched to the depth of subcutaneous tissue. Each tube is biflared on its deep end so that the suture makes the right-angle turns smoothly, and has a support bar on its superficial end over which the suture is tied. The tubes are made in 1 cm graduations from 1.5 to 7.5 cm. These measurements do not include the superficial ends which extend above the skin's surface. Therefore, one measures the depth of the subcutaneous panniculus and selects tubes in the next longer length. Prior to the main closure of the incision, the several retention sutures are placed at 4-5 cm intervals. #2 Monofilament Nylon has been the suture of choice. Each suture is brought into the incision, and then passed beneath the subcutaneous panniculus through the layers of deep fascia and muscle down into the peritoneal cavity. A maneuver that guarantees a full-thickness bite of the muscle and fasciae, but prevents any entrapment of bowel by the suture, is then to turn the needle and pass the suture superficial to the peritoneum, or fused peritoneum and posterior rectus sheath, to the other side. There this maneuver is reversed, i.e., the needle is passed into the peritoneal cavity, and then turned and
FIG. 2. Author's technique. Note short (1 cm) segment of suture within peritoneal cavity on each side. Tube inserted into incision keeps all force at fascial and muscle level, yet suture is accessible for removal. See text for explanation of force vectors.
FIG. 3. Deep fascia closed. The retention suture is being passed through a retention-suture-wound tube.
brought out through the peritoneum, fasciae, and muscle, leaving only 1 cm of suture within the cavity (Fig. 2), to exit into the incision deep to the subcutaneous tissue. The ends of these sutures are clamped and laid aside as the layer closure is carried out. With such a minimal amount of the retention suture within the peritoneal cavity on each side, the sutures can be safely tied blindly after the main wound closure of peritoneum and fasciae is completed. After the deep closure is completed, but before the subcutaneous fascia is sutured, the retention sutures are passed through the wound tubes (Fig. 3) and the tubes slid into the incision. After sighting through each tube to be sure the suture is not twisted, the surgeon ties the suture as the assistant applies counter pressure downward to counteract the upward pull during tying (Fig. 4). Considerable tension on these sutures at these intervals has been well tolerated by muscle and fasciae. As with all sutures, there is a compressive force applied against the
FIG. 4. Wound tube in incision, and retention suture has been tied. This prototype tube is in two pieces.
SMITH
~ ~ ~ ., . 0 Ann.
Surg. July 1975 -
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FIG. 5. Same case 14 days after hemigastrectomy and vagotomy. Wound tubes, with the contained retention sutures, protrude through the inci-
FIG. 7. Same case three weeks later, 5 weeks postoperatively. Note that the healed sinus openings are almost invisible in the scar, and there is no
sion.
crosshatching.
layers being sutured (see vectors on left in Fig. 2), but healing. At the time of removal (Figs. 5 and 6), the suthis is limited to the deep fasciae and muscle. If one tures are cut, the wound tubes wiggled out, and the considers these as a single layer, all of the force is hori- sutures removed. The tube sinuses are then cleaned out zontal, as desired (see single vector on right in Fig. 2). with sterile applicator sticks. Within a couple of days the The subcutaneous fascia and skin are closed between openings close, and within several weeks the healed sinus the emerging tubes. If a continuous suture is used for the openings cannot be distinguished in the incisional scar, subcutaneous fascia, it is better to lock it on both sides of and, of course, there is no crosshatching (Fig. 7). each tube, thereby avoiding any binding around the This technique has now been used in over 60 major tubes. If a continuous skin suture is used, it is merely abdominal cases without deep-wound separation, subpassed around each tube. Wound dressings should be sequent incisional hernia, or skin and subcutaneous inpadded appropriately between the tubes. Postoperative- jury. Except for the discharge of one Polydek fascial ly, some dried serum and fibrin collects in and around the suture two months postoperatively, after which the sinus tubes, but this is of no consequence. closed, all tube sinuses have promptly healed. It is my practice to leave retention sutures in for apIn only one instance has there been any subcutaneous proximately 14 days, varying this somewhat for conveni- infection due, possibly, to the technique: a moderately ence and considering the possibilities of delayed wound obese patient was probably responsible for introducing a S. aureus infection along only one side of the track of his lowest retention suture when he changed his dressing at home several times between the twelfth and seventeenth postoperative days. Patients should not change their dressings before the tubes are out. In several contaminated cases mild subcutaneous infection probably was minimized by the tubes serving as drains. It would appear that this technique grants the surgeon all of the benefits of efficiently placed retention sutures without exacting any payment in terms of skin and subcutaneous tissue damage.
Addendum }:.
:::e.}U)-,
FIG. 6. Retention sutures and tubes have been removed and played. Note the small tube sinus openings.
are
dis-
Since submission of the manuscript, this technique has been successfully applied in an additional 15 cases. Most recently, one-piece polypropylene devices have been used.
From The Department of Surgery, Through-and-through retention sutures are inherently inefficient Madison General Hospital, and prone to produce skin and subcutaneous damage. Most surMadison, Wisconsin geons are reluctant to permanently bury non-absorbable retention sutures. This new technique uses tube conduits to bring the retention sutures from deep fascial level to above the skin-surface, where they are available for removal. Thus, the sutures do non-absorbable material, there is a reluctance to permanot cross the skin and subcutaneous tissue, and they exert maxi- nently bury them under considerable tension because of mal efficiency at the deep fascial layers. This method has been permanent patient discomfort and potential problems if used in over 60 cases without deep-wound separation, and cominfection occurs. Therefore, the sutures are brought out plications have been minimal.
RETENTION SUTURES are used commonly in abdominal surgery to protect the main wound closure by exerting tension on the fascial and muscular layers several centimeters lateral to the main suture lines. They are indicated, especially, in the very obese, those with chronic pulmonary disease, malignancies, debility, and in those patients in whom postoperative abdominal distention can be anticipated because of the nature of the pathology. However, some surgeons use them almost routinely since their use can allow a somewhat simpler main wound closure, such as the use of continuous sutures. The technique of placing retention sutures varies from surgeon to surgeon. Commonly, they are placed through-and-through, traversing the peritoneal cavity from side to side (Fig. 1), and thus having the potential of trapping bowel between suture and peritoneum. Because retention sutures are made of quite heavy Submitted for publication March 21, 1975. Reprint requests: Dean Barton Smith, M.D., 20 S. Park Street, Madison, Wisconsin 53715.
through the subcutaneous panniculus and skin, and tied externally across the incision, where they are available for removal. Various methods have been devised in an attempt to protect the skin and subcutaneous tissue from damage, the most common being passing the sutures through rubber bolsters (Fig. 1). More recently various bridge devices have been used. These techniques attempt to dissipate the pressure consequent on adequate tension on the suture over a wide area, thereby minimizing damage. Unfortunately, the laws of force demand that the force applied to the skin be equal to that applied to the fascia, and the skin and subcutaneous tissue add little strength to the abdominal wall. Furthermore, by applying vectors, it is obvious that in all through-and-through techniques the direction of pull at the fascial level is 450 away from the desired horizontal plane (Fig. 1). It is clear that throughand-through retention sutures are inherently inefficient and have been a mixel blessing. If tied sufficiently tight to relieve the main wound closure of much of the abdominal-wall tension, skin and subcutaneous damage are likely to occur, especially in the obese patient. If not tied tightly, such sutures do not provide primary protec-
26
VOl. 182 NO. I
REMOVABLE BURIED RETENTION SUTURE
27
r7 ~E
-:'
=L
XS-
FIG. 1. Commonly used technique of placing retention sutures. Note potential trapping space between suture and peritoneum. Vector arrows illustrate net direction of force at the turning points of the suture in the posterior fascia and skin.
tion of the incision, and if there is partial separation of the incision, their bowstringing invites fistulization. A new technique has been developed which completely avoids these hazards by bringing the retention sutures from fascial level to above-skin level through retentionsuture-wound tubes, their length matched to the depth of subcutaneous tissue. Each tube is biflared on its deep end so that the suture makes the right-angle turns smoothly, and has a support bar on its superficial end over which the suture is tied. The tubes are made in 1 cm graduations from 1.5 to 7.5 cm. These measurements do not include the superficial ends which extend above the skin's surface. Therefore, one measures the depth of the subcutaneous panniculus and selects tubes in the next longer length. Prior to the main closure of the incision, the several retention sutures are placed at 4-5 cm intervals. #2 Monofilament Nylon has been the suture of choice. Each suture is brought into the incision, and then passed beneath the subcutaneous panniculus through the layers of deep fascia and muscle down into the peritoneal cavity. A maneuver that guarantees a full-thickness bite of the muscle and fasciae, but prevents any entrapment of bowel by the suture, is then to turn the needle and pass the suture superficial to the peritoneum, or fused peritoneum and posterior rectus sheath, to the other side. There this maneuver is reversed, i.e., the needle is passed into the peritoneal cavity, and then turned and
FIG. 2. Author's technique. Note short (1 cm) segment of suture within peritoneal cavity on each side. Tube inserted into incision keeps all force at fascial and muscle level, yet suture is accessible for removal. See text for explanation of force vectors.
FIG. 3. Deep fascia closed. The retention suture is being passed through a retention-suture-wound tube.
brought out through the peritoneum, fasciae, and muscle, leaving only 1 cm of suture within the cavity (Fig. 2), to exit into the incision deep to the subcutaneous tissue. The ends of these sutures are clamped and laid aside as the layer closure is carried out. With such a minimal amount of the retention suture within the peritoneal cavity on each side, the sutures can be safely tied blindly after the main wound closure of peritoneum and fasciae is completed. After the deep closure is completed, but before the subcutaneous fascia is sutured, the retention sutures are passed through the wound tubes (Fig. 3) and the tubes slid into the incision. After sighting through each tube to be sure the suture is not twisted, the surgeon ties the suture as the assistant applies counter pressure downward to counteract the upward pull during tying (Fig. 4). Considerable tension on these sutures at these intervals has been well tolerated by muscle and fasciae. As with all sutures, there is a compressive force applied against the
FIG. 4. Wound tube in incision, and retention suture has been tied. This prototype tube is in two pieces.
SMITH
~ ~ ~ ., . 0 Ann.
Surg. July 1975 -
:*.
_
W
x.S.
~
~
~
~
~
~
~
~
~
~
~
~
~
~
~
~
~
~
~~.
i:. _|
FIG. 5. Same case 14 days after hemigastrectomy and vagotomy. Wound tubes, with the contained retention sutures, protrude through the inci-
FIG. 7. Same case three weeks later, 5 weeks postoperatively. Note that the healed sinus openings are almost invisible in the scar, and there is no
sion.
crosshatching.
layers being sutured (see vectors on left in Fig. 2), but healing. At the time of removal (Figs. 5 and 6), the suthis is limited to the deep fasciae and muscle. If one tures are cut, the wound tubes wiggled out, and the considers these as a single layer, all of the force is hori- sutures removed. The tube sinuses are then cleaned out zontal, as desired (see single vector on right in Fig. 2). with sterile applicator sticks. Within a couple of days the The subcutaneous fascia and skin are closed between openings close, and within several weeks the healed sinus the emerging tubes. If a continuous suture is used for the openings cannot be distinguished in the incisional scar, subcutaneous fascia, it is better to lock it on both sides of and, of course, there is no crosshatching (Fig. 7). each tube, thereby avoiding any binding around the This technique has now been used in over 60 major tubes. If a continuous skin suture is used, it is merely abdominal cases without deep-wound separation, subpassed around each tube. Wound dressings should be sequent incisional hernia, or skin and subcutaneous inpadded appropriately between the tubes. Postoperative- jury. Except for the discharge of one Polydek fascial ly, some dried serum and fibrin collects in and around the suture two months postoperatively, after which the sinus tubes, but this is of no consequence. closed, all tube sinuses have promptly healed. It is my practice to leave retention sutures in for apIn only one instance has there been any subcutaneous proximately 14 days, varying this somewhat for conveni- infection due, possibly, to the technique: a moderately ence and considering the possibilities of delayed wound obese patient was probably responsible for introducing a S. aureus infection along only one side of the track of his lowest retention suture when he changed his dressing at home several times between the twelfth and seventeenth postoperative days. Patients should not change their dressings before the tubes are out. In several contaminated cases mild subcutaneous infection probably was minimized by the tubes serving as drains. It would appear that this technique grants the surgeon all of the benefits of efficiently placed retention sutures without exacting any payment in terms of skin and subcutaneous tissue damage.
Addendum }:.
:::e.}U)-,
FIG. 6. Retention sutures and tubes have been removed and played. Note the small tube sinus openings.
are
dis-
Since submission of the manuscript, this technique has been successfully applied in an additional 15 cases. Most recently, one-piece polypropylene devices have been used.
