In debilitated patients with low preoperative albumin and long abdominal incisions, retention sutures are often advisable, but surgeons generally avoid them because in order to bring the fascia together, they have to tie the sutures tightly. The postoperative result can be ulceration of the skin and pressure necrosis, with infection and a painful wound. Retention sutures in midline incisions must be tied tightly because often the skin protrudes more medially than the underlying fascia, which tends to retract away from the line of closure. Therefore, when the retention sutures are placed in a through-and-through manner, the skin edges come together first and each suture must be tightened further in order for the fascia to come together.

Figure 22.1 shows the use of sutures where the through-and-through suture is placed with the fascia edges slightly retracted so that the retention suture has to be tied tightly in order to bring the fascia together. If one places a clamp (such as a Kocher clamp) on the fascia and pulls it toward the center of the incision, the suture can be placed through the skin, subcutaneous fat, and then the musculoaponeurotic layers in a way that would transfix the edge of the fascia in a more medial position (Fig. 22.2).

Using a far-near–near-far type of suture in placing retention sutures allows the edges of the fascia to come together first, however. Then the retention suture can be tied lightly, without compressing the underlying skin and subcutaneous fat. As the needle of the retention suture is placed on the skin, it is displaced laterally as the skin is engaged, to retract the skin away from the center of the closure (Fig. 22.3). Similarly, as the suture is about to traverse the layers of the opposite side, with the fascia pulled toward the midline, the skin is retracted laterally, using the fingers of the nondominant hand, so that it will be transfixed as the suture goes through in a laterally retracted position.