There are many techniques for managing pilonidal sinus disease. I would be interested to know which you refer and how you decide which technique to perform if you use more than one.
An acute abscess is managed with an incision and drained to release the pus, and reduce the inflammation and pain and followed up with meticulous attention to hair and debris removal and wound packing. This procedure usually can be performed in the office with local anesthesia.
A chronic small in size sinus usually will need to be excised, and I usually prefer primary closure with flaps. In this case due to higher chance of infection I keep closer follow up, and in case of beginning of an infection, I prefer to cut my sutures, and convert to open technique.
Finally, in chronic cases, with extremely obese patients, bad co-operation, many recurrences e.t.c. I generally decide a wide excision, and leave the wound heal in secondary intention. This usually requires several weeks of regular dressing changes until it heals fully.
The main techniq is Limberg flep. If the size of sinus tissue is small (3 cm in diameter) ı prefer Karyadakis flep.
There's no doubt that treating pilonidal disease is more challenging than treating colon cancer! Having working for many different people in the Southwest it seems to be a battle between excision and primary closure (what most people give a shot to first, use Ethibond or Nylon) or secondary intention with wound packing.
Few odd people do flaps and we have had a lot of success (in Glos and BRI) with VAC dressings. There's a nice ppt presentation online by John Bascom where he explains his technique. As far as I understand the key with these is going off the midline to avoid the shearing forces. Tis worth checking out:
www.pilonidal.org/_assets/powerPiontPresentation/bascom_cleft_lift.ppt
Otherwise I'm sure our Greek and European colleague have the most experience and I'd be guided by them.
What is your personal preference Mr. Lund?
BW,
JB.
I vary my technique used dependent on the severity of disease and how symptomatic the patient is. Many patients adopt a watch and wait policy, in those I do operate on I use a bascombs procedure as primary procedure, which has low morbidity, and sometimes repeat if needed. For the more difficult to manage patients and those with large sinuses who fail on these procedures, I offer a cleft closure or limberg flap. These ops have significant morbidity and often a large wound, which has a 10-20% chance of wound breakdown.
agree with colleagues in saying that the type of treatment depends on the size of the sinus, and the severity of the inflammation.
I wanted to ask if anyone has experience of the treatment of sinus small and not inflamed with preparations of silver and quartz.
1. Acute abscess small and lateral: Bascom's procedure with longitudinal incison
to drain abscess, small diamond shaped incisions to excise sinuses and coring
out tracks leaving all wounds to heal by secondary intention.
2. Large abscess involving midline. Wide local excision of abscess and sinuses and
leave open with dressing or VAC and delayed primary closure at 7 days.
3. Chronic sinus. Cleft lift modification of Karydakis Flap with preservation of
subcutaneous fat.
4. Recurrence after 1. & 2. = 3.
5. Recurrence after 3.. Rhomboid /Lindberg Flap
6. Dedicated clinic/nurse to manage patients, wounds, hair removal and
patient/parent education.
Techniques using flaps should be used only by special indication. An acute pilo needs an acute treatment and the clinical best results (not the best published results) are the old fashioned surgical ones. Why do you ask? Thinking of a trial?
Acute inflammatory/ suppurative presentation- I follow the basic principles of managing suppuration/inflammation.
Established sinus disease according to choice of patient after informing him about the procedures/ expected outcomes i.e. either excision & allowing healing by secondary intention or excision + primary closure by a rotation flap (Rhomboid/ Limberg's)
Recurrent pilonidal disease- Limberg's flap
I am comfortable with Karydakis technique;usually it suffices for all types provided you go for complete mobilisation.
As you know well, different techniques are avalable for the treatment of pilonidal sinus disease. The parameter for the treatment choice are the stage of disease, the attitude of the patient toward the disease, patient's compliance and the preference of the surgeon. In addition, the preference of the outpatient treatment unit is important. Keeping all this in mind, decision making is not too easy.
Primary closure with asymmetrical flap.
Selection factors: deepness of the gluteal cleft, hairiness, number and location of primary and secondary pits, and types of previous procedures (if any)
Yesterday I had a case with the sinus far away left of the midline, more than 5-6 cm away, so I resected everything and made a rotation flap to cover the gap. Here Karydakis does not work.
I think the treatment of sinus is independent of the affected area, regardless of the size of the sinus. I realize the total resection of the sinus, to pre sacral aponeurosis with rigorous hemostasis, and after I cover with gas soaked in vaseline, occluding the orifice. The dressings should be changed twice daily. The total recovery time is longer, about 90 days, but the recurrence rate is less than 3% in two years.
We have a large amount of pilonidal diseases in our Hospital.Excision of the cyst and fistula if it is located in midline and concomitant marsipulization for us is the mainstay treatment.If the fistula is in a lateral position usually communicates with the midline ,so we excize it we close the wound and we left open the midline with marsipulization which offers fast recovery in about 10 days healing of the wound.In case of inflammation just andibiotic,abscess formation just open it and 40 days later excision of the pilonidal sinus.In case with multiple fistulas spare skin excision with marsupulizations offers complete cure.
My favoured technique is rhomboid excision and Limberg flap rotation. I use routinely.
why is nobody talking about postoperative hair removal either by laser or hair removing creams as part of the treatment. With whatever surgical procedure employed I find recurrance rates far lower when the patient has diligently removed the hair from the surrounding area either by temporary or permanent measures
I talk about this issue routinely, but I prefer hair removing creams in general,
I usually perform excision and primary closure. I perform rotation flaps only in the case of multiple eccentric tips
Primary closure has higher recurrence rate amd wound failure. In my opinion it should not be use to treat of pilonidal sinus disease.It should not be forgotten that this area is deep, wet, hairy and under pressure. Also, tension will be big problem for wound.
Actually, the technique I use is the so called "mininvasive technique" with biopunch. This allow a better recovery of the patient. At present time, in our Institution, we have not conclusive data about long-term recurrence of disease, but our impression is that the ratio is similar to the traditional techniques. Meanwhile, we can affirm that the kind of intervention we perform is better tolerated by the patient and allow a faster recovery.
I think we are having this discussion because there is no definite answer! The same technique for a similar sinus in a similar setting for a similar patient may not necessarily work every time. I suggest we accept this as a good starting point.
I think the asymptomatic ones that have never flared up should be left alone. The patient or their partner might want to pull out the loose hairs with a pair of tweezers now and again to reduce the risk of blockage.
I think when an abscess is incised and drained, it should be left open. Although I believe in aspiration and in excision and primary closure of superficial abscesses, I think in the current situation, the presence of foreign material (hair) precludes either approach. A “one off” abscess should not mean a commitment to a pilonidal sinus operation down the track.
Midline and “just off” midline “pits” do reasonably well with excision and primary closure using an asymmetrical flap (Modified Karidakas’ Flap Repair). I think the larger flaps should be helped with a vac drain for a few days. I think a failed Karidakas should be curetted and re-sutured over a drain for a second chance at a delayed primary healing. I tell patients that a “full on” failure of healing after a Karidakas is not necessary a failure as “excision and repeated packing” is a form of treatment that is accepted by many surgeons.
I don’t think marsupialisation adds anything. I think the concept in this situation is flawed and the results are not that good. I have used a vac dressing a few times with success. I think skin grafts don’t work well. I never saw them work in the 1980’s so I never use them.
I think the larger sinuses with multiple and well-off- midline openings need a well-drawn, well-planned and well-performed rhomboid (occasionally double rhomboid) flap repair under generous antibiotic cover.
I think local “skin” conditions should be detected and treated independent of the “pilo”.
Despite the classic teaching about the hairs having come from “elsewhere”, I think all patients should use (almost literally) a handful of hair removing crème centred over the sinus about once a month as required to reduce the risk of recurrence. Other generally agreed upon no-operative measures are also important.
This photo below is of a recurrent complicated sinus that healed well with a rhomboid flap repair:
Thanks everyone. I ask because I thought there would be a wide range of practice. It is a stubborn condition, disappointingly so for patient and surgeon alike.
I agree with all the above about treating acute abscesses - drain the pus.
Its what to do with the vast majority of cases - a few midline pits with or without a secondary track, which very often seems to extend cephalad and slightly laterally.
I think its important not to make the treatment worse than the disease. I think (with the greatest respect to those who do this) that Limberg flap as a first line is too invasive and leaves quite a scar (young ladies in particular, in whom the disease is not uncommon, do not like the thought of this). Also, excision and leaving to heal by secondary intention is difficult for young people and often keeps them away from normal activities, whilst granulation occurs. It is also expensive in terms of dressings and nursing time (let alone the cost to the economy of lost days at work).
For the vast majority of cases first line for me is curretage under local or general anaesthesia, followed by filling of the newly cleaned and fresh sinuses with fibrin glue.
This allows return to full activities within a couple of days and no requirement for dressing. A trial previously performed showed equivalent healing and recurrence to Bascom's I procedure and using it for over 7 years patients report high satisfaction and healing. Glue can be used where there has been treatment failure after excisional surgery.
If recurrence occurs after glue, I have a discussion with the patient. Often they opt for the glue once more (especially if has been over a year since the original procedure), but otherwise second line is a Karydakis procedure.
I do occasionally perform limberg flaps - bit only for late presenting (where the natal cleft is woody from repeated infection and inflammation) and multiply recurrent disease.
I usually perform open procedure using a CO2 laser intead of a scalp. Laser allows better and faster healing and makes possible to vaporize more tissue to prevent recurrence. It also less painful and do not keeps patients out of their activities for too long, although dressing is still a problem. I guess fibrin glue is a good procedure.
I am surprised no one has mentioned Bascom's procedure in which a lateral releiving incision is made to drain the abscess cavity and the sinus(es) are excised with a fine blade and closed. The absence of any shearing force allows the lateral incision, which is left open with a wick dressing to heal up in 2-4 weeks. Simple and effective!
Over 26 years I have performed 84 pilonidal cystectomies. At first I did most as primary excision and closure due to my training but was unhappy with recurrences. I also left a few open (one with marsupialization). However, I have found the Bascom cleft closure technique and the karydakis flap most useful over time and more durable. During the first 42 I did primary excision and closure in 57%, excision and leaving open in 2 % , the Bascom cleft closure in 23% and a lateral bascom technique in 14%. In the last 42 I have done primary in only 19%, bascom lateral in 5%, no open procedures, bascom cleft closure in 43% and the karydakis procedure in 33%. I have had 4 recurrences that I am aware of , and 3 occurred in the primary group and 1 in the open (marsupialization) group. There were 2 dehiscences due to hematomas in the bascom cleft closure group but these all healed. The extent and nature of the disease determines whether I use the bascom or karydakis approach and this is working very well. I have not been inclined to try the limberg flap.
Non of the technique/procedure is full proof from the recurrence point of view.But the consideration about obese(deep natal cleft with large amount of subcutaneous fat) and thin may be one point. rhomboid flap repair in obese with permanent hair removal is good to us while Z plasty does not yield good results in these cases.Though we are using Kshar Sutra technique ( being practiced in India and some other parts of world for Fistula in Ano) too, find less invasive with a few recurrences after permanent hair removal.
When there is no infection, even if there was some time before, I prefer excision and primary closure with rotation flap. However I obtain informed consent for the risk of failure.
When there is chronic draining infection, my choice is excise and leave the wound open for secondary healing.
For abscess, it is incision and drainage only.
I completely agree with Mr. Abraham. Personnally, I try to flatten the natal cleft whatever the rechnique I use
I did many simple cystectomies with or without closure, but I abandoned it after frequent recurrences. Karidakis-Bascom's procedure (http://www.pilonidal.org) is my choice. Incision is larger and healing lasts longer but recurrences are rare.
Dear Mr. Lund,
this is because it is published before our birth I think.
Look at the original publication:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1543901/
Mr G Karydakis the inventor of the homonymous operation considered and taught that hair insertion is the cause of the pilonidal sinus. He had the largest series worldwide and his recurrence rate was extremely low 1%. He attributed such results on two principal characteristics of his operation. these are 1.replacement of the whole wound away from midline (recurrences always occur in the midline)
and 2.the base of the flap becomes the resulting new swallower cleft (so hairs do not collect readily)
I still use Golligher's method, in narrow defects, flaps being reserved for wide defects closure of which causes tension and wound failure. Post - op removal of back hairs is essential in preventing further episodes.
Dr Lund, thank you for your good questions and comments. My favorite technique is rhombiod excision and Limberg flap rotation. Paricularly it is very effective and rational method for the middle and large size pilonidal sinus or sinus with multiple orifices. This method creates a flat area, changes hair direction and removes deep intergluteal sulcus. But, I think there is no ideal thechnique with fully advantage. It is impossible. Every method has some advantages or some disadvantages. Our technique must be excellent. I believe that it must be primary aim for us. If we know two or three method for the treatment of pilonidal sinus for every situation will be better. And also 0% recurrence rate is almost impossible.
Rhombiod excision and Limberg flap rotation method is very good choice in obese pts and pts with deep natal cleft.
Bascom' pit picking or cleft lift. Under no circumstances midline incisions-
If it is just a sinus not ever an abscess, what is the best treatment?
See German S3 guideline:
A pilonidal abscess should initially be locally incised followed by one of the
definitive treatment methods after regression of the acute inflammation. Primary
definitive excision with open granulation is possible but associated with a long lasting healing time and higher recurrence rate. Primary excision and wound closure in case of abscess is associated with an increased morbidity and should be avoided The basic treatment method of the chronic pilonidal disease is the surgical excision. Open wound treatment after pilonidal excision is associated with a low postoperative morbidity rate; however, this method is complicated by a considerably prolonged wound healing. The minimally invasive procedures (e.g. pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to open procedures. Excision followed by a primary midline wound closure bears no advantages to other methods and should be avoided. An off-midline surgical approach can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis procedure are the two best described methods.
Karydakis in most of the cases but occasionally a Rombergs flap once I find that you need to excise more
I perform trephine surgery or, as I call it, the "Bascom-Gips" procedure. I am in the process of publishing the outcome on 214 patients. Enclosed (in the 2nd page of the attachment), the preliminary results on 110 patients, that we presented last month in Treviso (Italy) at the National Conference of the Italian Society of Colon & Rectal Surgery (SICCR). Also, you can view video at the following link (pardon poor quality).
https://www.youtube.com/watch?v=EgA8xRKErjU&feature=em-upload_owner
Primary excision and closure by z- plasty is my preferred method as it changes the direction of final scar and no dependent area left . No chances of reoccurrence
Wonderful discussion. I'm about to go in for my 5 excision procedure in about 4-5 years. General consensus out here in Hong Kong among surgeons is that this is chiefly a 'western' condition and hence there is a lack of the kind of experience in dealing with patients that is shown here. Based on what I have read here, I am inclined to ask my surgeon here to go for either the Bascom or the karydakis and not the Limburg. Any advice welcome.
Military hospital in Greece is high volume center of pilonidal disease surgery.Personally I've operated almost 800 cases in the last 10 years(p.d with 1 or 2 or multiple fistula with perianal extension,with cellulitis of the buttocks etc).I don,t know about glue but asymmetrical or oblique elliptical incisions in an attempt to keep incisions out of the natal clef like Karydakis either Bascom are good alternative but not the mainstay.I believe that elliptical incision with a technique initially cut the skin and subsequently follow(without real cutting!) with the knife the fistula sinus at the end and finally excision of it,and restoration with marsipulization is the mainstay.Follow up consisting of wash of the trauma from the patient with betadine scrubb, and clean it with simple water.The patient has partial activity from the first day and full activity from 8th post day after taking the sutures out.He must continue to wash its trauma by himself(without the need of nurse)for 40 days,and somebody else must shave the trauma area for 6 monthsand believe me there will be no recurence.We must follow our trauma instructions by seeing the patient once per 10days.In case that the patient isn;t consistent with our instructions and a reccurence might be happened we can perform
a modified Bascom by open minimally the wound and take out the hairs from cleft.Another good advantage with this technique is that the natal clef is in its physical position with excellent cosmetic result.
Dear Dr. Lund,
knowing that the only criterion for patient satisfaction in the long term is recurrence free survival, the choice is between the flap procedures (adv flap Bascom / mKarydakis; rot flap mLimberg/mDufourmentel) and the other asymmetrical closure techniques. A review incorporating more than 75.000 patients will show soon that these techniques do achieve recurrence rates of loer than 10% after 10 years, which is the best we can achieve today. As long as we do not control our recurrence rate (in relation to time since surgery) we will continue stumbling through the fog and do eminence based surgery.
Kind regards,
Dietrich Doll
We prefer a modified Bascom's procedure, combining "pit picking" removal of enlarged hair follicles with either a tubular fistulectomy or laser ablation of the fistula tract. Laser permanent hair removal is very valuable in curing non healing wounds after failed radical surgery.
Wide excision, open wound, secondary healing.
The least recurrence rate, which matters most where I practice.
Also very good final aesthetic result.
It seems there is some degree of secondary differentiation in this area.
1. For the purulent type “abscess” im doing abscess drainage with sinotomy .
2. For the large size with multiple openinig that involve large area im doing excision with flap.
3.for the small type im doing the minimal excision primary closure techniqu with recurrence rate < 4% .
The technique is published in my paper on research gate .