Retention Suture Removal from Midline Abdominal Incision
Retention sutures should be removed 14-21 days postoperatively by cutting the suture material at the skin surface on one side and pulling through from the opposite side, though current evidence does not support their routine use in midline laparotomy closures.
Evidence Regarding Retention Sutures
The 2023 World Society of Emergency Surgery guidelines explicitly state that no consensus exists on the routine use of retention sutures for midline laparotomy closures, as the expert panel could not reach the required 80% agreement threshold 1. High-quality evidence demonstrating that retention sutures decrease wound dehiscence rates is lacking 1.
However, one randomized controlled trial showed retention sutures reduced wound dehiscence from 13.3% to 4% (p=0.007) in high-risk patients with multiple risk factors for impaired wound healing 2. This suggests selective use may be appropriate in specific high-risk populations rather than routine application.
Technical Approach to Removal
Timing of Removal
- Remove retention sutures at 14-21 days postoperatively to allow adequate fascial healing while minimizing tissue reaction and patient discomfort 2
- This extended timeframe accounts for the deeper tissue layers involved and the need for complete fascial tensile strength development 3
Removal Technique
- Cut the suture material flush with the skin on one side of the incision using sterile scissors or a scalpel blade 4
- Grasp the suture on the opposite side with forceps and pull steadily through the tissue tract in one smooth motion 4
- Inspect each removal site for signs of infection, granulation tissue, or suture sinus formation 5
- Apply steri-strips across the incision after removal to provide additional support during the final healing phase 6
Important Clinical Considerations
When Retention Sutures Were Placed
Retention sutures are typically placed through all layers including skin, subcutaneous tissue, rectus muscle, and abdominal fascia 2. Understanding this full-thickness placement is critical because:
- Removal may cause more discomfort than standard skin suture removal due to deeper tissue involvement 2
- Consider local anesthetic infiltration at removal sites if the patient experiences significant pain 6
- Monitor for delayed complications including suture sinuses and granulomas at the deep tissue level 5
Post-Removal Monitoring
- Assess wound integrity immediately after removal to ensure no fascial dehiscence occurs 2
- Instruct patients to avoid heavy lifting (>10 pounds) for an additional 2-4 weeks after retention suture removal 3
- Watch for late incisional hernia development, which occurs in approximately 4% of midline closures regardless of retention suture use 5
Common Pitfalls to Avoid
- Do not remove retention sutures prematurely (before 14 days), as this increases the risk of wound dehiscence in the high-risk patients for whom they were placed 2
- Avoid excessive force during removal, which can cause tissue trauma and bleeding from the deep tissue tracts 4
- Do not assume retention sutures prevent all dehiscence risk—the underlying patient risk factors (malnutrition, infection, contamination) remain present even after appropriate healing time 2
- Recognize that retention sutures do not significantly increase postoperative pain beyond the first 3 days, so pain complaints after this period warrant evaluation for other complications 2