Retention sutures are heavy gauge percutaneous sutures, usually with some form of skin protection, used in high tension wound closures to support primary wound closure. Typically, the term “retention suture” has been used in the general surgical literature to discuss closure of open and/or complex laparotomy wounds. In these cases, a large caliber (#0 to #2) suture is placed through multiple layers of tissue including skin, fascia and muscle. In order to prevent skin breakdown and failure (ripping), the suture is usually paired with a device, such as a bolster, bridge or tubing, to offset pressure.
Suture retention bridges were originally developed to cushion the effect of the suture and reduce its tendency to tear into the skin (“cheesewire”). When used for large laparotomy wounds, these bridges are large and quite inflexible to withstand the large forces used in these closures. The ETHICON retention bridge (see below) is an example of this type of bridge.
Many other types of cushioning material have been used to enable retention suture placement in laparotomy wound closure. These include buttons, plates, sponges and elastic tubing.
The SUTUREGARD® ISR device was designed “from the ground up” to be used as a retention suture for high tension skin wound closures.
Suture retention bridges in a laparotomy wound closure
ETHICON retention suture bridges pictured next to SUTUREGARD® ISR devicesThe SUTUREGARD® ISR device has a novel, patented soft and flexible structure that flattens with increasing suture tension to augment surface contact and reduce pressure from a high tension suture. The image below highlights how SUTUREGARD® ISR reduces the pressure when compared with an unprotected suture.
Pressure profile of SUTUREGARD® ISR-protected high tension retention suture (left) versus identical unprotected suture (right). 33% lower average pressure and 40% lower peak (red and yellow) pressure with SUTUREGARD® ISR compared to unprotected sutureThe SUTUREGARD® ISR device’s arched bridge design elevates the suture above the skin which prevents direct downward crushing pressure at the peri-incisional skin and also changes the exit vector of the suture (exiting suture travels more perpendicular to the plane of the skin rather than directly overlying the skin and crushing it).
The use of a high tension suture in combination with a SUTUREGARD® ISR will lead to a relaxation (stress relaxation) of a skin wound over time. In a recent published clinical trial, the use of a SUTUREGARD® ISR retention suture with an average force of just over 2kg resulted in 65% lower scalp wound closure tension after 30 minutes.
For providers who use a SUTUREGARD® ISR-protected retention suture, it is important to understand the most recent CPT coding of such closures. A retention suture like the SUTUREGARD® ISR will result in a complex linear code rather than intermediate, so long as it is part of a layered closure (ie: buried absorbable sutures). As mentioned in previous blogs (link), the use of undermining is NOT advised with the SUTUREGARD® ISR, since it is often unnecessary and will potentially increase wound complications.